Provider Demographics
NPI:1508901448
Name:ST. JOSEPH HEALTH SERVICES OF RI
Entity Type:Organization
Organization Name:ST. JOSEPH HEALTH SERVICES OF RI
Other - Org Name:PULMONARY GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:SNR. VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:CFO
Authorized Official - Phone:401-456-2000
Mailing Address - Street 1:825 CHALKSTONE AVE
Mailing Address - Street 2:N. CAMPUS BUSINESS OFFICE, ATTN: R. SOARES
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:401-456-2525
Mailing Address - Fax:401-456-6742
Practice Address - Street 1:200 HIGH SERVICE AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5113
Practice Address - Country:US
Practice Address - Phone:401-456-3000
Practice Address - Fax:401-456-6742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2013-02-08
Deactivation Date:2007-09-19
Deactivation Code:
Reactivation Date:2009-12-01
Provider Licenses
StateLicense IDTaxonomies
RIHOS00110207RP1001X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISJ09267Medicaid
RI299006122Medicare PIN