Provider Demographics
NPI:1285748871
Name:WOODRIDGE MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:WOODRIDGE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:POTENZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-943-1860
Mailing Address - Street 1:351 BUDLONG RD
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6001
Mailing Address - Country:US
Mailing Address - Phone:401-943-1860
Mailing Address - Fax:401-943-8952
Practice Address - Street 1:351 BUDLONG RD
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6001
Practice Address - Country:US
Practice Address - Phone:401-943-1860
Practice Address - Fax:401-943-8952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI80110112683170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9020788Medicaid
RI9000049Medicaid
RI9000168Medicaid
RI9000168Medicaid
RIC90053Medicare UPIN
RIH02004Medicare UPIN