Provider Demographics
NPI:1669622478
Name:JACK P MOURAD,MD,INC
Entity type:Organization
Organization Name:JACK P MOURAD,MD,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOURAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-461-8450
Mailing Address - Street 1:226 AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-2852
Mailing Address - Country:US
Mailing Address - Phone:401-461-8450
Mailing Address - Fax:401-461-8640
Practice Address - Street 1:226 AUBURN ST
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-2852
Practice Address - Country:US
Practice Address - Phone:401-461-8450
Practice Address - Fax:401-461-8640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI8219207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9002703Medicaid
RI110179243OtherRAILROAD MEDICARE
RI22724OtherNEIGHBORHOOD HEALTH PLAN
RI2703-4OtherBLUECROSS/BLUESHIELD
RI04-01308OtherUNITED HEALTH CARE
RI64476OtherHARVARD PILGRIM HEALTH CARE
RI9002703Medicaid
RI709006214Medicare PIN