Provider Demographics
NPI:1336163088
Name:JENOURI, ILSE (MD)
Entity type:Individual
Prefix:
First Name:ILSE
Middle Name:
Last Name:JENOURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:164 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-519-1604
Practice Address - Fax:401-272-0538
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10752207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI11/09/2006OtherNHPRI
MA0158861Medicaid
RI1336163088OtherNPI
RI939025129OtherRI MEDICARE GROUP NUMBER
RI7009395Medicaid
MA12/29/2008OtherTUFTS HEALTH PLAN
9300114370OtherRAILROAD MEDICARE
RI408921OtherBCBSRI
RI408921OtherBCBSRI
MA0158861Medicaid