=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760565824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. JOSEPH HOSPITAL CARDIOLOGY FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 HIGH SERVICE AVE MARIAN HALL
-----------------------------------------------------
City | NORTH PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02904-5113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-456-3456
-----------------------------------------------------
Fax | 401-456-3773
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 HIGH SERVICE AVE MARIAN HALL
-----------------------------------------------------
City | NORTH PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02904-5113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-456-3456
-----------------------------------------------------
Fax | 401-456-3773
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. DAVID J FORTUNATO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 401-273-1350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246W00000X
-----------------------------------------------------
Taxonomy Name | Cardiology Technician
-----------------------------------------------------
License Number | MD05244
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------