Provider Demographics
NPI:1912972050
Name:MOURAD, JACK P (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:P
Last Name:MOURAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-2852
Mailing Address - Country:US
Mailing Address - Phone:401-461-8450
Mailing Address - Fax:401-461-8640
Practice Address - Street 1:226 AUBURN ST
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-2852
Practice Address - Country:US
Practice Address - Phone:401-461-8450
Practice Address - Fax:401-461-8640
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI8219207P00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI22724OtherNEIGHBORHOOD HEALTH PLAN
RI9002703Medicaid
RI04-01308OtherUNITED HEALTH CARE
RI110179243OtherRAILROAD MEDICARE
RI2703-4OtherBLUECROSS/BLUESHIELD
RI64476OtherHARVARD PILGRIM HEALTH CARE
RI2703-4OtherBLUECROSS/BLUESHIELD
RI007060510Medicare PIN