Basic Information
| Provider Information | |||||||||
| NPI: | 1225073638 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE MIRIAM HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST | ||||||||
| Address2: | SUITE 101, CREDENTIALING DEPARTMENT | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446779 | ||||||||
| FaxNumber: | 4014446912 | ||||||||
| Practice Location | |||||||||
| Address1: | 146 W RIVER ST STE 11A | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029042609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017938770 | ||||||||
| FaxNumber: | 4017938709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | KIRSHNER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4014447914 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0809X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 163WP0809X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | MI72815 - PSYCH | 05 | RI | MEDICAID | 1225073638 | 05 | RI | MEDICAID |