Provider Demographics
NPI:1346394616
Name:JENNIFER SOUTHER MD INC
Entity Type:Organization
Organization Name:JENNIFER SOUTHER MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-334-4500
Mailing Address - Street 1:30 MARTIN ST
Mailing Address - Street 2:UNIT 30A
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-5321
Mailing Address - Country:US
Mailing Address - Phone:401-334-4500
Mailing Address - Fax:401-312-0096
Practice Address - Street 1:30 MARTIN ST
Practice Address - Street 2:UNIT 30A
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-5321
Practice Address - Country:US
Practice Address - Phone:401-334-4500
Practice Address - Fax:401-312-0096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10848207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI01-02493OtherUNITED HEALTH CARE
RI32087-4OtherBLUE CROSS
RI409677OtherBLUE CHIP OF RI
RI12001018OtherMULTIPLAN
RIMD10848OtherLIC
RIAA242OtherHARVARD PILGRIM
RI01-02493OtherUNITED HEALTH CARE
RI409677OtherBLUE CHIP OF RI
RI12001018OtherMULTIPLAN