Provider Demographics
NPI:1760565824
Name:ST. JOSEPH HOSPITAL CARDIOLOGY FOUNDATION
Entity Type:Organization
Organization Name:ST. JOSEPH HOSPITAL CARDIOLOGY FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORTUNATO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-273-1350
Mailing Address - Street 1:200 HIGH SERVICE AVE
Mailing Address - Street 2:MARIAN HALL
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5113
Mailing Address - Country:US
Mailing Address - Phone:401-456-3456
Mailing Address - Fax:401-456-3773
Practice Address - Street 1:200 HIGH SERVICE AVE
Practice Address - Street 2:MARIAN HALL
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5113
Practice Address - Country:US
Practice Address - Phone:401-456-3456
Practice Address - Fax:401-456-3773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD05244246W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246W00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9000123Medicaid