Healthcare Provider Details

I. General information

NPI: 1467190496
Provider Name (Legal Business Name): BROWN MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 WAMPANOAG TRL
RIVERSIDE RI
02915-2232
US

IV. Provider business mailing address

DEPT 3010, PO BOX 986524
BOSTON MA
02298-6524
US

V. Phone/Fax

Practice location:
  • Phone: 401-649-4020
  • Fax: 401-649-4021
Mailing address:
  • Phone: 401-443-4992
  • Fax: 401-537-7241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DONNA GORDON
Title or Position: RCM DIRECTOR
Credential:
Phone: 401-443-5107