Provider Demographics
NPI:1861274813
Name:EMMANUEL MEDICAL SERVICES LLC
Entity type:Organization
Organization Name:EMMANUEL MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMOS
Authorized Official - Middle Name:
Authorized Official - Last Name:ADELAIYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-200-8242
Mailing Address - Street 1:10 DORRANCE ST STE 700
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-2014
Mailing Address - Country:US
Mailing Address - Phone:401-200-8242
Mailing Address - Fax:401-415-0418
Practice Address - Street 1:1417 DOUGLAS AVE STE 2
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-4057
Practice Address - Country:US
Practice Address - Phone:401-200-8242
Practice Address - Fax:401-415-0418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIEM17385Medicaid