Provider Demographics
NPI:1396722666
Name:PRIME HEALTHCARE SERVICES-LANDMARK LLC
Entity type:Organization
Organization Name:PRIME HEALTHCARE SERVICES-LANDMARK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-769-4100
Mailing Address - Street 1:196 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-4712
Mailing Address - Country:US
Mailing Address - Phone:401-769-4100
Mailing Address - Fax:401-765-6024
Practice Address - Street 1:115 CASS AVE
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4705
Practice Address - Country:US
Practice Address - Phone:401-769-4100
Practice Address - Fax:401-765-6024
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LANDMARK MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-28
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00117273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7000251Medicaid
MA900934OtherHARVARD PILGRIM HEALTH
RI0000000010OtherBLUE CROSS
RI1015600OtherBEACON HEALTH STRATEGIES
RI4100011Medicaid
MA903289OtherTUFTS HEALTH PLAN (IP)
RIH00104OtherBLUE CHIP
RI5012812OtherUNITED HEALTHCARE
MD903288OtherTUFTS HEALTH PLAN (OP)
RI222921474OtherTRICARE
MA7029241Medicaid
RIOP00011Medicaid
RI5012812OtherUNITED HEALTHCARE