Healthcare Provider Details

I. General information

NPI: 1275810434
Provider Name (Legal Business Name): THE MIRIAM HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 CORLISS ST STE E1
PROVIDENCE RI
02904-2602
US

IV. Provider business mailing address

15 LA SALLE SQ
PROVIDENCE RI
02903-1814
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-7401
  • Fax:
Mailing address:
  • Phone: 14-446-7794
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberHOS00122
License Number StateRI

VIII. Authorized Official

Name: MR. PETER K MARKELL
Title or Position: EVP & CFO
Credential:
Phone: 401-444-7914