Provider Demographics
NPI:1134264062
Name:ST. JOSEPH HEALTH SERVICES OF RI
Entity type:Organization
Organization Name:ST. JOSEPH HEALTH SERVICES OF RI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SNR. VISE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:401-456-2525
Mailing Address - Street 1:200 HIGH SERVICE AVE
Mailing Address - Street 2:ATTN: ROSE SOARES
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5113
Mailing Address - Country:US
Mailing Address - Phone:401-456-2525
Mailing Address - Fax:401-456-6742
Practice Address - Street 1:21 PEACE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1510
Practice Address - Country:US
Practice Address - Phone:401-456-4325
Practice Address - Fax:401-456-4250
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOSEPH HEALTH SERVICES OF RI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2013-01-25
Deactivation Date:2007-09-19
Deactivation Code:
Reactivation Date:2009-12-01
Provider Licenses
StateLicense IDTaxonomies
RIHOS00110133NN1002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI509025253OtherMEDICARE P-TAN
RISJ48636Medicaid