Healthcare Provider Details

I. General information

NPI: 1013052976
Provider Name (Legal Business Name): ST. JOSEPH HEALTH SERVICES OF RI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date: 09/19/2007
Reactivation Date: 12/01/2009

III. Provider practice location address

200 HIGH SERVICE AVE
NORTH PROVIDENCE RI
02904-5113
US

IV. Provider business mailing address

825 CHALKSTONE AVE N. CAMPUS BUSINESS OFFICE, ATTN: R. SOARES
PROVIDENCE RI
02908-4728
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-3000
  • Fax: 401-752-8248
Mailing address:
  • Phone: 401-456-2525
  • Fax: 401-456-6742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberHOS00110
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberHOS00110
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberHOS00110
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberHOS00110
License Number StateRI

VIII. Authorized Official

Name: MICHAEL E CONKLIN JR.
Title or Position: SNR. VICE PRESIDENT
Credential: CFO
Phone: 401-456-3000