Provider Demographics
NPI:1952501421
Name:EDGEWOOD MEDICAL LLC
Entity Type:Organization
Organization Name:EDGEWOOD MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:R
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-275-0700
Mailing Address - Street 1:251 PARK AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02905-2647
Mailing Address - Country:US
Mailing Address - Phone:401-275-0700
Mailing Address - Fax:401-275-0775
Practice Address - Street 1:251 PARK AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02905-2647
Practice Address - Country:US
Practice Address - Phone:401-275-0700
Practice Address - Fax:401-275-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty