Healthcare Provider Details

I. General information

NPI: 1306123476
Provider Name (Legal Business Name): PROVIDENCE INTERVENTIONAL ASSOCIATES II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HIGHLAND AVE STE 100
PROVIDENCE RI
02906-2740
US

IV. Provider business mailing address

100 HIGHLAND AVE STE 100
PROVIDENCE RI
02906-2740
US

V. Phone/Fax

Practice location:
  • Phone: 401-277-9729
  • Fax: 401-277-9730
Mailing address:
  • Phone: 401-277-9729
  • Fax: 401-277-9730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JONAH LICHT
Title or Position: OWNER
Credential: M.D.
Phone: 401-277-9729