Basic Information
| Provider Information | |||||||||
| NPI: | 1689657249 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMAGING NETWORK OF RHODE ISLAND, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9132 | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024469132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038939784 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 CHALKSTONE AVE | ||||||||
| Address2: | ROGERS WILLIAMS MEDICAL CENTER | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014562204 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 11/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | STAINKEN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DELEGATE | ||||||||
| AuthorizedOfficialTelephone: | 4013342423 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2627-9 | 01 | RI | BLUE SHIELD | OTHER | 9002627 | 05 | RI | MEDICAID | 9775617 | 05 | MA | MEDICAID |