Provider Demographics
NPI:1629493135
Name:PROSPECT CHARTERCARE PHYSICIANS, LLC
Entity type:Organization
Organization Name:PROSPECT CHARTERCARE PHYSICIANS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133VN1006X, 207Q00000X, 207RE0101X, 207RG0100X, 207RH0003X, 207RI0200X, 207RP1001X, 207T00000X, 2084N0400X, 208600000X, 208800000X, 207R00000X
RIPR98473207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty