Healthcare Provider Details

I. General information

NPI: 1134514276
Provider Name (Legal Business Name): OCEAN STATE PRIMARY CARE CENTER OF COVENTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 TIOGUE AVE
COVENTRY RI
02816-6116
US

IV. Provider business mailing address

982 TIOGUE AVE
COVENTRY RI
02816-6116
US

V. Phone/Fax

Practice location:
  • Phone: 401-821-6800
  • Fax: 401-821-8513
Mailing address:
  • Phone: 401-821-6800
  • Fax: 401-821-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN H. MARTIN
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 401-821-6800