Healthcare Provider Details

I. General information

NPI: 1114186715
Provider Name (Legal Business Name): ST JOSEPH HEALTH SERVICES OF RHODE ISLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 PEACE ST
PROVIDENCE RI
02907-1510
US

IV. Provider business mailing address

200 HIGH SERVICE AVE 4TH FL MARION HALL
NORTH PROVIDENCE RI
02904-5113
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-3309
  • Fax: 401-456-3762
Mailing address:
  • Phone: 401-456-3309
  • Fax: 401-456-3762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberHOS00110
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberHOS00110
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberHOS001100
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberHOS00110
License Number StateRI
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberHOS00110
License Number StateRI

VIII. Authorized Official

Name: MR. JOHN FOGERTY
Title or Position: PRESIDENT - CEO
Credential:
Phone: 401-456-3309