Basic Information
| Provider Information | |||||||||
| NPI: | 1477587871 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAY HEALTHCARE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 BACON ST | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028605542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017223560 | ||||||||
| FaxNumber: | 4017243120 | ||||||||
| Practice Location | |||||||||
| Address1: | 249 ROOSEVELT AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028602134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017248400 | ||||||||
| FaxNumber: | 4013651100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FACTEAU | ||||||||
| AuthorizedOfficialFirstName: | JOYCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4017248400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | RN35771 | RI | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | KH43328 | 05 | RI | MEDICAID |