Healthcare Provider Details

I. General information

NPI: 1376372243
Provider Name (Legal Business Name): CHARTERCARE ROGER WILLIAMS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 CHALKSTONE AVE
PROVIDENCE RI
02908-4728
US

IV. Provider business mailing address

825 CHALKSTONE AVE
PROVIDENCE RI
02908-4728
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-2000
  • Fax: 401-456-2029
Mailing address:
  • Phone: 401-456-2000
  • Fax: 401-456-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY LIEBMAN
Title or Position: CEO
Credential:
Phone: 401-456-2001