Healthcare Provider Details

I. General information

NPI: 1265857007
Provider Name (Legal Business Name): OCEAN STATE PRIMARY CARE CENTER OF WESTERLY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 FRANKLIN STREET
WESTERLY RI
02891
US

IV. Provider business mailing address

77 FRANKLIN STREET
WESTERLY RI
02891
US

V. Phone/Fax

Practice location:
  • Phone: 401-596-6464
  • Fax: 401-348-8660
Mailing address:
  • Phone: 401-596-6464
  • Fax: 401-348-8660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JONATHAN HAMILTON MARTIN
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 401-596-6464