Provider Demographics
NPI:1386863496
Name:MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL
Other - Org Name:MEMORIAL HOSPITAL EEG GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-729-2000
Mailing Address - Street 1:111 BREWSTER ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4400
Mailing Address - Country:US
Mailing Address - Phone:401-729-2000
Mailing Address - Fax:
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4400
Practice Address - Country:US
Practice Address - Phone:401-729-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-25
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084D0003XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyDiagnostic NeuroimagingGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9006134Medicaid
RI0299006134Medicare PIN