| Name: | South County Family Medicine, Inc. |
| Jurisdiction: | Rhode Island |
| Entity type: | Domestic Profit Corporation |
| Status: | Revoked Entity |
| Date of Organization in Rhode Island: | 28 Mar 2001 (24 years ago) |
| Date of Dissolution: | 28 Aug 2013 (11 years ago) |
| Date of Status Change: | 28 Aug 2013 (11 years ago) |
| Identification Number: | 000117563 |
| ZIP code: | 02818 |
| County: | Kent County |
| Principal Address: | 3461 SOUTH COUNTY TRAIL SUITE 202, EAST GREENWICH, RI, 02818, USA |
| Purpose: | TO PROVIDE MEDICAL SERVICES TO PATIENTS |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1225041064 | 2006-08-14 | 2011-03-02 | 1111 MAIN ST, HOPE VALLEY, RI, 028321610, US | 1111 MAIN ST, HOPE VALLEY, RI, 028321610, US | |||||||||||||||||||||||||
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| Phone | +1 401-539-0283 |
| Fax | 4015396741 |
Authorized person
| Name | DR. JONATHAN BERTMAN |
| Role | CEO |
| Phone | 4015390283 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | RI8814 |
| State | RI |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | SC42150 |
| State | RI |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SOUTH COUNTY FAMILY MEDICINE 401(K) PROFIT SHARING PLAN & TRUST | 2013 | 050516401 | 2014-08-05 | SOUTH COUNTY FAMILY MEDICINE | 58 | |||||||||||||||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2014-08-05 |
| Name of individual signing | KATHLEEN REPOLI |
| Valid signature | Filed with authorized/valid electronic signature |
| Role | Employer/plan sponsor |
| Date | 2014-08-05 |
| Name of individual signing | KATHLEEN REPOLI |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| JEFFREY F. CHASE-LUBITZ, ESQ. | Agent | DONOGHUE BARRETT & SINGAL PC 10 WEYBOSSET STREET, PROVIDENCE, RI, 02903, USA |
| Name | Role | Address |
|---|---|---|
| JONATHAN BERTMAN, M.D. | PRESIDENT | 3461 SOUTH COUNTY TRAIL, SUITE 202 EAST GREENWICH, RI 02818 USA |
| Number | Name | File Date |
|---|---|---|
| 201327278710 | Revocation Certificate For Failure to File the Annual Report for the Year | 2013-08-28 |
| 201321878790 | Revocation Notice For Failure to File An Annual Report | 2013-06-03 |
| 201289686110 | Annual Report | 2012-02-14 |
| 201176222900 | Annual Report | 2011-03-02 |
| 201059958010 | Annual Report | 2010-03-03 |
| 200943541530 | Annual Report | 2009-03-04 |
| 200807821550 | Annual Report | 2008-03-14 |
| 200805149250 | Statement of Change of Registered/Resident Agent | 2008-01-04 |
Date of last update: 08 Oct 2024
Sources: Rhode Island Department of State
