Provider Demographics
NPI:1285059287
Name:PROSPECT CHARTERCARE RWMC, LLC
Entity type:Organization
Organization Name:PROSPECT CHARTERCARE RWMC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JON
Authorized Official - Last Name:ELDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-788-1249
Mailing Address - Street 1:825 CHALKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:401-456-2000
Mailing Address - Fax:401-456-2029
Practice Address - Street 1:825 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4728
Practice Address - Country:US
Practice Address - Phone:401-456-2000
Practice Address - Fax:401-456-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-27
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIHOS00133101YA0400X
103TA0400X, 104100000X, 1041C0700X, 174400000X, 207R00000X, 207RA0401X, 207RH0003X, 207RP1001X, 207X00000X, 2084P0802X, 208600000X, 2086X0206X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIU100152467Medicare PIN