NPIMap

Organization Active NPI

Prospect Chartercare Sjhsri, LLC

  • Psychiatric Hospital Unit
  • North Providence, RI
National Provider Identifier
1396160396
Registry record updated Jan 15, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric Hospital UnitTaxonomy code 273R00000X
License
HOS00110 Issued in RI
Legal business name
PROSPECT CHARTERCARE SJHSRI, LLC
Practice address
200 High Service Ave
North Providence, RI 02904-5113
Phone
(401) 456-3000
Fax
(401) 456-3028
NPI assigned
Feb 27, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 15, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Robert Jon Elders
Title
Secretary
Phone
(714) 788-1249

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital Unit 273R00000X HOS00110 RI Primary

Addresses

Primary practice location

200 High Service Ave
North Providence, RI 02904-5113

Mailing address

200 High Service Ave
North Providence, RI 02904-5113
Phone (401) 456-3000

Other identifiers 1

IdentifierTypeStateIssuer
41S0005MedicaidRI

Other names 1

  • St. Joseph Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in RI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140404001743 RI Part A Provider - Hospital 7315179314 Practice locations: North Providence, RI

Hospital certification: CCN 41S005

Legal name
PROSPECT CHARTERCARE SJHSRI LLC
Doing business as
OUR LADY OF FATIMA HOSPITAL
Organization structure
LLCProprietary
Incorporated
Aug 21, 2013 in RI
Enrollment address
200 High Service Ave
North Providence, RI 29045113
Other Hospital Practice Location
Hospital subgroups
Psychiatric, Psychiatric unit

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Locations

200 High Service Ave
Ofc
North Providence, RI 02904

Ownership & related parties

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Sang Bum Lee Individual 5% Or Greater Indirect Ownership Interest Jun 1, 2014 66.67%
Corporate OfficerSVP Nov 13, 2014
Corporate DirectorDirector Jun 1, 2014
Jeffrey H Liebman Individual Corporate OfficerCeo Oct 29, 2018
W-2 Managing Employee Oct 29, 2018
Robert Elders Individual Corporate OfficerSecretary Jun 15, 2020
Prospect East Holdings, Inc. Organization, Los Angeles, CA For-profit 5% Or Greater Indirect Ownership Interest Jun 1, 2014 85%
Eric Samuels Individual Corporate OfficerTreasurer Jun 3, 2019
Alfredo Sabillo Individual Corporate OfficerAssistant Treasurer Jul 21, 2020
Ivy Holdings Inc Organization, Los Angeles, CA For-profit 5% Or Greater Indirect Ownership Interest Jun 1, 2014 85%
William M Gorenstein Individual Corporate OfficerSVP Aug 15, 2016
David & Alexa Topper Family Trust Organization, Beverly Hills, CA 5% Or Greater Indirect Ownership Interest Jun 1, 2014 33.33%
Ivy Intermediate Holding, Inc. Organization, Los Angeles, CA For-profit 5% Or Greater Indirect Ownership Interest Jun 1, 2014 85%
Prospect Chartercare, LLC Organization, N Providence, RI For-profit 5% Or Greater Direct Ownership Interest Jun 1, 2014 100%
David R Topper Individual Corporate OfficerSVP Nov 13, 2014
Corporate DirectorDirector Jun 1, 2014
Other Jun 1, 2014
Chamber Inc Organization, Los Angeles, CA Corporation 5% Or Greater Indirect Ownership Interest Jun 1, 2021 100%
Prospect Medical Holdings Inc Organization, Los Angeles, CA For-profit 5% Or Greater Indirect Ownership Interest Jun 1, 2014 85%

Facilities with the same owner 12

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 32

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 32

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1393459200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1610668800000",
    "number": "1396160396",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 HIGH SERVICE AVE",
            "city": "NORTH PROVIDENCE",
            "state": "RI",
            "postal_code": "029045113",
            "telephone_number": "401-456-3000",
            "fax_number": "401-456-3028"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 HIGH SERVICE AVE",
            "city": "NORTH PROVIDENCE",
            "state": "RI",
            "postal_code": "029045113",
            "telephone_number": "401-456-3000",
            "fax_number": "401-456-3028"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROSPECT CHARTERCARE SJHSRI, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-02-27",
        "last_updated": "2021-01-15",
        "certification_date": "2021-01-15",
        "status": "A",
        "authorized_official_last_name": "ELDERS",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "JON",
        "authorized_official_title_or_position": "SECRETARY",
        "authorized_official_telephone_number": "714-788-1249"
    },
    "taxonomies": [
        {
            "code": "273R00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Unit",
            "state": "RI",
            "license": "HOS00110",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "41S0005",
            "state": "RI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St. Joseph Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "St. Joseph Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in North Providence, RI

Sources for this page

Verify at the official NPI Registry.