Provider Demographics
NPI:1457898215
Name:PROSPECT BLACKSTONE VALLEY SURGICARE, LLC
Entity Type:Organization
Organization Name:PROSPECT BLACKSTONE VALLEY SURGICARE, LLC
Other - Org Name:BLACKSTONE VALLEY SURGICARE
Other - Org Type:Other Name
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ELDERS
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:310-943-4500
Mailing Address - Street 1:1526 ATWOOD AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-3289
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1526 ATWOOD AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3289
Practice Address - Country:US
Practice Address - Phone:401-459-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical