Provider Demographics
NPI:1104124734
Name:WICKFORD FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:WICKFORD FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACHATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-450-2111
Mailing Address - Street 1:PO BOX 118
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-0118
Mailing Address - Country:US
Mailing Address - Phone:401-450-2111
Mailing Address - Fax:
Practice Address - Street 1:320 PHILLIPS ST
Practice Address - Street 2:SUITE 204
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-5149
Practice Address - Country:US
Practice Address - Phone:401-450-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI08781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty