Provider Demographics
NPI:1205563731
Name:ROGER WILLIAMS MEDICAL CENTER
Entity type:Organization
Organization Name:ROGER WILLIAMS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-456-2070
Mailing Address - Street 1:825 CHALKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4728
Practice Address - Country:US
Practice Address - Phone:401-456-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILP05722OtherSTATE OF RHODE ISLAND DEPARTMENT OF HEALTH