Provider Demographics
NPI:1568667848
Name:WELLNORTH MEDICAL LLC
Entity Type:Organization
Organization Name:WELLNORTH MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CALCATTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-438-1010
Mailing Address - Street 1:1630 MINERAL SPRING AVE
Mailing Address - Street 2:2
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-4043
Mailing Address - Country:US
Mailing Address - Phone:401-438-1010
Mailing Address - Fax:
Practice Address - Street 1:1630 MINERAL SPRING AVE
Practice Address - Street 2:2
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-4025
Practice Address - Country:US
Practice Address - Phone:401-438-1010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
RICP408256OtherBLUE CHIP
RIH32399Medicare UPIN
RICP408256OtherBLUE CHIP