Provider Demographics
NPI:1518987981
Name:ROGER WILLIAMS MEDICAL CENTER
Entity Type:Organization
Organization Name:ROGER WILLIAMS MEDICAL CENTER
Other - Org Name:ROGER WILLIAMS PHYSICIAN ASSISTANT GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PREDIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BELCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-456-2000
Mailing Address - Street 1:825 CHALKSTONE AVE
Mailing Address - Street 2:N. CAMPUS BUSINESS OFFICE
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:401-456-2000
Mailing Address - Fax:401-456-6718
Practice Address - Street 1:825 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4728
Practice Address - Country:US
Practice Address - Phone:401-456-2000
Practice Address - Fax:401-456-6718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9002981Medicaid
RI9002981Medicaid