Healthcare Provider Details

I. General information

NPI: 1134264062
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: 01/25/2013
Certification Date:
Deactivation Date: 09/19/2007
Reactivation Date: 12/01/2009

III. Provider practice location address

21 PEACE ST
PROVIDENCE RI
02907-1510
US

IV. Provider business mailing address

200 HIGH SERVICE AVE ATTN: ROSE SOARES
NORTH PROVIDENCE RI
02904-5113
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-4325
  • Fax: 401-456-4250
Mailing address:
  • Phone: 401-456-2525
  • Fax: 401-456-6742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberHOS00110
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberHOS00110
License Number StateRI

VIII. Authorized Official

Name: MICHAEL CONKLIN
Title or Position: SNR. VISE PRESIDENT
Credential: CFO
Phone: 401-456-2525