Basic Information
| Provider Information | |||||||||
| NPI: | 1073705943 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMMA PENDLETON BRADLEY HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446779 | ||||||||
| FaxNumber: | 4014446912 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 VETERANS MEMORIAL PKWY | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029155061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446966 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | KIRSCHNER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | AARON | ||||||||
| AuthorizedOfficialTitleorPosition: | EXEC. VP / CFO | ||||||||
| AuthorizedOfficialTelephone: | 4014447914 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | EP41762 | 05 | RI | MEDICAID |