=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669622478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACK P MOURAD,MD,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2008
-----------------------------------------------------
Last Update Date | 12/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 226 AUBURN ST
-----------------------------------------------------
City | CRANSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02910-2852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-461-8450
-----------------------------------------------------
Fax | 401-461-8640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 226 AUBURN ST
-----------------------------------------------------
City | CRANSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02910-2852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-461-8450
-----------------------------------------------------
Fax | 401-461-8640
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JACK P MOURAD
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 401-461-8450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 8219
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------