Provider Demographics
NPI:1508898909
Name:FAIRLAWN PRIMARY CARE, INC
Entity Type:Organization
Organization Name:FAIRLAWN PRIMARY CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-475-3063
Mailing Address - Street 1:886 MINERAL SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-3322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:886 MINERAL SPRING AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-3322
Practice Address - Country:US
Practice Address - Phone:401-475-3063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI09843207R00000X
RINPP37132363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9003461Medicaid
RI7006714Medicaid
RI7006714Medicaid