Provider Demographics
NPI:1043507734
Name:INFECTIOUS DISEASES ASSOCIATES OF RHODE ISLAND
Entity type:Organization
Organization Name:INFECTIOUS DISEASES ASSOCIATES OF RHODE ISLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:G
Authorized Official - Last Name:FORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:401-766-3428
Mailing Address - Street 1:69 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-9418
Mailing Address - Country:US
Mailing Address - Phone:401-766-3428
Mailing Address - Fax:401-767-1633
Practice Address - Street 1:115 CASS AVENUE - 3RD FLOOR
Practice Address - Street 2:C/O LANDMARK MEDICAL
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895
Practice Address - Country:US
Practice Address - Phone:401-769-4100
Practice Address - Fax:401-767-1633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD07281207RI0200X
RI06195207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty