Provider Demographics
NPI:1912265323
Name:EMMA PENDLETON BRADLEY HOSPITAL
Entity Type:Organization
Organization Name:EMMA PENDLETON BRADLEY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:401-444-5640
Mailing Address - Street 1:1011 VETERANS MEMORIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-5061
Mailing Address - Country:US
Mailing Address - Phone:401-444-5640
Mailing Address - Fax:
Practice Address - Street 1:1011 VETERANS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-5061
Practice Address - Country:US
Practice Address - Phone:401-444-5640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIHOS00123283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIBH06997Medicaid