Provider Demographics
NPI: | 1457772543 |
---|---|
Name: | PRIME HEALTHCARE SERVICES LANDMARK LLC |
Entity Type: | Organization |
Organization Name: | PRIME HEALTHCARE SERVICES LANDMARK LLC |
Other - Org Name: | LANDMARK PHYSICIAN OFFICE SERVICES |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRACTICE ADMINISTRATOR |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | STACY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | VIENS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 401-769-4100 |
Mailing Address - Street 1: | 219 CASS AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | WOONSOCKET |
Mailing Address - State: | RI |
Mailing Address - Zip Code: | 02895-4736 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 401-769-4100 |
Mailing Address - Fax: | 401-766-9575 |
Practice Address - Street 1: | 219 CASS AVE |
Practice Address - Street 2: | |
Practice Address - City: | WOONSOCKET |
Practice Address - State: | RI |
Practice Address - Zip Code: | 02895-4736 |
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: | PRIME HEALTHCARE SERVICES LANDMARK LLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2013-12-17 |
Last Update Date: | 2023-01-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
No | 2086X0206X | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | Group - Multi-Specialty |
No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Multi-Specialty |
No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
RI | PR95770 | Medicaid | |
RI | PR95770 | Medicaid |