=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396954640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 11/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 BREWSTER STREET MEMORIAL HOSPITAL OF RHODE ISLAND
-----------------------------------------------------
City | PAWTUCKET
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-729-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 174 ARMSTICE BLVD.
-----------------------------------------------------
City | PAWTUCKET
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-729-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | FRANCIS R DIETZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-729-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------