Provider Demographics
NPI:1629055751
Name:LANDMARK MEDICAL CENTER
Entity Type:Organization
Organization Name:LANDMARK MEDICAL CENTER
Other - Org Name:LANDMARK MC PATHOLOGY DEPT.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MACINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-769-4100
Mailing Address - Street 1:196 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-4712
Mailing Address - Country:US
Mailing Address - Phone:401-769-4100
Mailing Address - Fax:401-765-6024
Practice Address - Street 1:115 CASS AVE
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4705
Practice Address - Country:US
Practice Address - Phone:401-769-4100
Practice Address - Fax:401-769-1744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00117207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA903288OtherTUFTS HEALTH PLAN (OP)
RI9006490Medicaid
MD903289OtherTUFTS HEALTH PLAN (IP)
RI9006490Medicaid