Healthcare Provider Details

I. General information

NPI: 1528359502
Provider Name (Legal Business Name): CONCENTRA HEALTH CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 MENDON RD SUITE 101A
CUMBERLAND RI
02864-3833
US

IV. Provider business mailing address

5080 SPECTRUM DRIVE SUITE 1200 WEST
ADDISON TX
75001-4624
US

V. Phone/Fax

Practice location:
  • Phone: 401-475-3000
  • Fax: 401-475-3204
Mailing address:
  • Phone: 972-364-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM TOM FOGARTY
Title or Position: PRESIDENT
Credential: MD
Phone: 972-364-8000