Healthcare Provider Details

I. General information

NPI: 1710169792
Provider Name (Legal Business Name): JAMES MARK BADGER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST APC 948
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-5480
  • Fax: 401-444-3492
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberPNS00001
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN00898
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: