Provider Demographics
NPI:1396844544
Name:GATEWAY PROFESSIONAL GROUP
Entity type:Organization
Organization Name:GATEWAY PROFESSIONAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FACTEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-724-8400
Mailing Address - Street 1:208 GOVERNOR ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3246
Mailing Address - Country:US
Mailing Address - Phone:401-490-3563
Mailing Address - Fax:401-490-3569
Practice Address - Street 1:208 GOVERNOR ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-3246
Practice Address - Country:US
Practice Address - Phone:401-490-3563
Practice Address - Fax:401-490-3569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI=========OtherEIN