Provider Demographics
NPI:1396090536
Name:BLACKSTONE MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:BLACKSTONE MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:RENNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-419-4772
Mailing Address - Street 1:PO BOX 845582
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-5582
Mailing Address - Country:US
Mailing Address - Phone:401-769-4100
Mailing Address - Fax:401-766-9575
Practice Address - Street 1:219 CASS AVENUE
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4741
Practice Address - Country:US
Practice Address - Phone:401-769-4100
Practice Address - Fax:401-766-9575
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEWARD MEDICAL HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-13
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00117207R00000X, 208600000X, 2086X0206X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI410011Medicare Oscar/Certification