Provider Demographics
NPI:1548332257
Name:OCEAN STATE PRIMARY CARE LLC
Entity type:Organization
Organization Name:OCEAN STATE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:FARHAT
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-739-4350
Mailing Address - Street 1:300 TOLL GATE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4447
Mailing Address - Country:US
Mailing Address - Phone:401-739-4350
Mailing Address - Fax:401-739-3759
Practice Address - Street 1:300 TOLL GATE RD STE 202
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4447
Practice Address - Country:US
Practice Address - Phone:401-739-4350
Practice Address - Fax:401-739-3759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10008207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
404939OtherB CHIP
309562OtherBCBS
400337OtherTUFTS
RI9004697Medicaid
2499OtherNHP
2499OtherNHP
404939OtherB CHIP
RI9004697Medicaid
RI119020734Medicare PIN