Provider Demographics
NPI: | 1629493135 |
---|---|
Name: | PROSPECT CHARTERCARE PHYSICIANS, LLC |
Entity Type: | Organization |
Organization Name: | PROSPECT CHARTERCARE PHYSICIANS, LLC |
Other - Org Name: | CHARTERCARE MEDICAL ASSOCIATES |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | SECRETARY |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ROBERT |
Authorized Official - Middle Name: | JON |
Authorized Official - Last Name: | ELDERS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 714-788-1249 |
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: | 401-456-2025 |
Mailing Address - Fax: | 401-456-2029 |
Practice Address - Street 1: | 1681 CRANSTON ST |
Practice Address - Street 2: | |
Practice Address - City: | CRANSTON |
Practice Address - State: | RI |
Practice Address - Zip Code: | 02920-5000 |
Practice Address - Country: | US |
Practice Address - Phone: | 401-944-6889 |
Practice Address - Fax: | 401-944-6726 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-02-20 |
Last Update Date: | 2021-08-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
133N00000X, 133VN1006X, 207Q00000X, 207R00000X, 207RE0101X, 207RG0100X, 207RH0003X, 207RI0200X, 207RP1001X, 207T00000X, 2084N0400X, 208600000X, 208800000X | ||
RI | PR98473 | 207N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 133N00000X | Dietary & Nutritional Service Providers | Nutritionist | Group - Multi-Specialty | |
No | 133VN1006X | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic | Group - Multi-Specialty |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty |