Provider Demographics
NPI:1669690418
Name:CRANSTON PEDIATRICS LLC DBA PARK PEDIATRICS INC
Entity type:Organization
Organization Name:CRANSTON PEDIATRICS LLC DBA PARK PEDIATRICS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:QUILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-274-6575
Mailing Address - Street 1:801 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-2036
Mailing Address - Country:US
Mailing Address - Phone:401-274-6575
Mailing Address - Fax:401-273-2597
Practice Address - Street 1:801 PARK AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-2036
Practice Address - Country:US
Practice Address - Phone:401-274-6575
Practice Address - Fax:401-273-2597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD11641208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI412877OtherHEALTHMATE
RIMD 11641OtherLICENSE NUMBER
RI30943OtherNEIGHBORHOOD HEALTH PLAN
RI31923-4OtherBLUE CROSS BLUE SHIELD
RI25-79403OtherUNITED HEALTH PLAN
RI412877OtherBLUE CHIP
RI9004316Medicaid
RI412877OtherHEALTHMATE