Provider Demographics
NPI:1568498392
Name:ROGER WILLIAMS MEDICAL CENTER
Entity Type:Organization
Organization Name:ROGER WILLIAMS MEDICAL CENTER
Other - Org Name:ROGER WILLIAMS NUTRITIONIST GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NEVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-456-2407
Mailing Address - Street 1:825 CHALKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:401-456-2677
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:401-456-2677
Practice Address - Fax:401-456-6718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIHOS00108133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI719081010Medicare PIN