Provider Demographics
NPI:1568494789
Name:GATEWAY HEALTHCARE, INC
Entity Type:Organization
Organization Name:GATEWAY HEALTHCARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:RENU
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTHARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-724-8400
Mailing Address - Street 1:249 ROOSEVELT AVE
Mailing Address - Street 2:STE 205
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-2134
Mailing Address - Country:US
Mailing Address - Phone:401-724-8400
Mailing Address - Fax:401-365-1100
Practice Address - Street 1:249 ROOSEVELT AVE
Practice Address - Street 2:STE 205
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-2134
Practice Address - Country:US
Practice Address - Phone:401-724-8400
Practice Address - Fax:401-365-1100
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
RIMD05601174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7001845Medicaid