Provider Demographics
NPI:1437232543
Name:PROVIDENCE SURGICAL CARE GROUP, INCORPORATED
Entity Type:Organization
Organization Name:PROVIDENCE SURGICAL CARE GROUP, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-454-0690
Mailing Address - Street 1:486 SILVER SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-1556
Mailing Address - Country:US
Mailing Address - Phone:401-454-0690
Mailing Address - Fax:401-454-4281
Practice Address - Street 1:486 SILVER SPRING ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1556
Practice Address - Country:US
Practice Address - Phone:401-454-0690
Practice Address - Fax:401-454-4281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPS32025Medicaid
RI339095979Medicare ID - Type Unspecified