Healthcare Provider Details

I. General information

NPI: 1043507734
Provider Name (Legal Business Name): INFECTIOUS DISEASES ASSOCIATES OF RHODE ISLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CASS AVENUE - 3RD FLOOR C/O LANDMARK MEDICAL
WOONSOCKET RI
02895
US

IV. Provider business mailing address

69 HIGHLAND AVE
WARWICK RI
02886-9418
US

V. Phone/Fax

Practice location:
  • Phone: 401-769-4100
  • Fax: 401-767-1633
Mailing address:
  • Phone: 401-766-3428
  • Fax: 401-767-1633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number06195
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD07281
License Number StateRI

VIII. Authorized Official

Name: DR. GLENN G FORT
Title or Position: CEO
Credential: MD, MPH
Phone: 401-766-3428