Provider Demographics
NPI:1346307485
Name:PRIMARY CARE MEDICAL ASSOCIATES OF CRANSTON INC
Entity type:Organization
Organization Name:PRIMARY CARE MEDICAL ASSOCIATES OF CRANSTON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:G
Authorized Official - Last Name:DEJESUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-461-5400
Mailing Address - Street 1:1596 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4130
Mailing Address - Country:US
Mailing Address - Phone:401-461-5400
Mailing Address - Fax:401-461-9039
Practice Address - Street 1:1596 BROAD ST
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02905-4130
Practice Address - Country:US
Practice Address - Phone:401-461-5400
Practice Address - Fax:401-461-9039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI10197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPC54016Medicaid
RI2982OtherNEIGHBORHOOD HEALTH
RI469187OtherTUFTS
RI759600OtherADVANTRA
RI709003200Medicare PIN