Provider Demographics
NPI:1972632255
Name:BLACKSTONE VALLEY OB GYN INC
Entity Type:Organization
Organization Name:BLACKSTONE VALLEY OB GYN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PENKALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-334-2229
Mailing Address - Street 1:6 BLACKSTONE VALLEY PL
Mailing Address - Street 2:SUITE 501
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-1179
Mailing Address - Country:US
Mailing Address - Phone:401-334-2229
Mailing Address - Fax:401-333-2454
Practice Address - Street 1:6 BLACKSTONE VALLEY PL
Practice Address - Street 2:SUITE 501
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-1179
Practice Address - Country:US
Practice Address - Phone:401-334-2229
Practice Address - Fax:401-333-2454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0010505Medicare PIN