Basic Information
| Provider Information | |||||||||
| NPI: | 1477583706 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GATEWAY HEALTHCARE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 249 ROOSEVELT AVE | ||||||||
| Address2: | STE 205 | ||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028602134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017248400 | ||||||||
| FaxNumber: | 4013651100 | ||||||||
| Practice Location | |||||||||
| Address1: | 249 ROOSEVELT AVE | ||||||||
| Address2: | STE 205 | ||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028602134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017248400 | ||||||||
| FaxNumber: | 4013651100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TACTACAN | ||||||||
| AuthorizedOfficialFirstName: | PEDRO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CRED COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4017248400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD100002 | RI | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | PT44450 | 05 | RI | MEDICAID |