Provider Demographics
| NPI: | 1598978744 |
|---|---|
| Name: | THE MIRIAM HOSPITAL |
| Entity Type: | Organization |
| Organization Name: | THE MIRIAM HOSPITAL |
| Other - Org Name: | THE MIRIAM HOSPITAL PROFESSIONAL SERVICES |
| Other - Org Type: | Other Name |
| Authorized Official - Title/Position: | E VP & CFO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | PETER |
| Authorized Official - Middle Name: | K |
| Authorized Official - Last Name: | MARKELL |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 401-444-7914 |
| Mailing Address - Street 1: | 117 ELLENFIELD ST |
| Mailing Address - Street 2: | SUITE 101 |
| Mailing Address - City: | PROVIDENCE |
| Mailing Address - State: | RI |
| Mailing Address - Zip Code: | 02905-4513 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 401-444-6779 |
| Mailing Address - Fax: | 401-444-6912 |
| Practice Address - Street 1: | 164 SUMMIT AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | PROVIDENCE |
| Practice Address - State: | RI |
| Practice Address - Zip Code: | 02906-2853 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 401-444-5640 |
| Practice Address - Fax: | 401-444-5462 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | LIFESPAN CORPORATION |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2007-05-07 |
| Last Update Date: | 2023-04-21 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 207ZC0500X, 207ZH0000X, 207ZM0300X, 207ZP0101X, 207ZP0102X, 207ZP0105X, 208600000X, 261QM1300X, 363AM0700X, 363AS0400X, 363L00000X, 363LA2200X | ||
| RI | HOS00122 | 261Q00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
| No | 207ZC0500X | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | Group - Multi-Specialty |
| No | 207ZH0000X | Allopathic & Osteopathic Physicians | Pathology | Hematology | Group - Multi-Specialty |
| No | 207ZM0300X | Allopathic & Osteopathic Physicians | Pathology | Medical Microbiology | Group - Multi-Specialty |
| No | 207ZP0101X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | Group - Multi-Specialty |
| No | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | Group - Multi-Specialty |
| No | 207ZP0105X | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | ||
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| RI | 0646 | Other | NHPRI VENDOR NO. |
