Healthcare Provider Details

I. General information

NPI: 1033464276
Provider Name (Legal Business Name): BLACKSTONE MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CASS AVE
WOONSOCKET RI
02895-4705
US

IV. Provider business mailing address

219 CASS AVENUE
WOONSOCKET RI
02895-4741
US

V. Phone/Fax

Practice location:
  • Phone: 401-769-4100
  • Fax:
Mailing address:
  • Phone: 401-769-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number00117
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number00117
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number00117
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number00117
License Number StateRI
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number00117
License Number StateRI
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number00117
License Number StateRI

VIII. Authorized Official

Name: MR. JAMES RENNA
Title or Position: CFO
Credential:
Phone: 617-419-4772