Healthcare Provider Details

I. General information

NPI: 1396844544
Provider Name (Legal Business Name): GATEWAY PROFESSIONAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 GOVERNOR ST
PROVIDENCE RI
02906-3246
US

IV. Provider business mailing address

208 GOVERNOR ST
PROVIDENCE RI
02906-3246
US

V. Phone/Fax

Practice location:
  • Phone: 401-490-3563
  • Fax: 401-490-3569
Mailing address:
  • Phone: 401-490-3563
  • Fax: 401-490-3569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: JOYCE A FACTEAU
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 401-724-8400