Provider Demographics
NPI:1962536730
Name:STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Entity type:Organization
Organization Name:STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:AXELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-222-5112
Mailing Address - Street 1:3 CAPITOL HL
Mailing Address - Street 2:ROOM 402
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-5034
Mailing Address - Country:US
Mailing Address - Phone:401-222-5112
Mailing Address - Fax:401-222-1256
Practice Address - Street 1:3 CAPITOL HL
Practice Address - Street 2:ROOM 402
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-5034
Practice Address - Country:US
Practice Address - Phone:401-222-5112
Practice Address - Fax:401-222-1256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0000031189OtherBLUE CROSS PROVIDER NUMBR