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  5. Southern New England Retina Associates PC

Southern New England Retina Associates PC

Company Details

Name: Southern New England Retina Associates PC
Jurisdiction: Rhode Island
Entity type: Professional Service Corporation
Status: Dissolved
Date of Organization in Rhode Island: 13 Dec 2005 (19 years ago)
Date of Dissolution: 31 Dec 2015 (9 years ago)
Date of Status Change: 31 Dec 2015 (9 years ago)
Identification Number: 000152156
ZIP code: 02906
County: Providence County
Principal Address: ONE RANDALL SQUARE UNIT 203, PROVIDENCE, RI, 02906, USA
Purpose: MEDICAL PRACTICE
Historical names: Retina Associates of Southeastern New England, Inc.
Retina Associates of Southern New England PC

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1548228794 2006-05-03 2011-07-20 1 RANDALL SQ, SUITE 203, PROVIDENCE, RI, 029042709, US 1 RANDALL SQ, SUITE 203, PROVIDENCE, RI, 029042709, US

Contacts
Phone +1 401-453-4600
Fax 4014530077

Authorized person
Name DR. MAGDALENA G KRZYSTOLIK
Role PRESIDENT
Phone 4014534600

Taxonomy
Taxonomy Code 207W00000X - Ophthalmology Physician
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 9004676
State RI
Issuer MEDICAID
Number 9762591
State MA
Issuer BCBS
Number M19151
State MA
Issuer TUFTS HEALTH CARE
Number 624129
State RI
Issuer AETNA
Number 7246790
State RI

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
SOUTHERN NEW ENGLAND RETINA ASSOCIATES RETIREMENT PLAN 2015 203935214 2016-09-26 SOUTHERN NEW ENGLAND RETINA ASSOCIATES, PC 10
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 4014534600
Plan sponsor’s address 1 RANDALL SQUARE, SUITE 203, PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2016-09-26
Name of individual signing MAGDALENA KRZYSTOLIK
Valid signature Filed with authorized/valid electronic signature
SOUTHERN NEW ENGLAND RETINA ASSOCIATES RETIREMENT PLAN 2014 203935214 2015-02-25 SOUTHERN NEW ENGLAND RETINA ASSOCIATES, PC 10
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 4014534600
Plan sponsor’s address 1 RANDALL SQUARE, SUITE 203, PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2015-02-25
Name of individual signing MAGDALENA KRZYSTOLIK
Valid signature Filed with authorized/valid electronic signature
SOUTHERN NEW ENGLAND RETINA ASSOCIATES RETIREMENT PLAN 2013 203935214 2014-04-14 SOUTHERN NEW ENGLAND RETINA ASSOCIATES, PC 11
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 4014534600
Plan sponsor’s address 1 RANDALL SQUARE, SUITE 203, PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2014-04-14
Name of individual signing MAGDALENA KRZYSTOLIK
Valid signature Filed with authorized/valid electronic signature
SOUTHERN NEW ENGLAND RETINA ASSOCIATES RETIREMENT PLAN 2012 203935214 2013-04-03 SOUTHERN NEW ENGLAND RETINA ASSOCIATES, PC 10
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 4014534600
Plan sponsor’s address 1 RANDALL SQUARE, SUITE 203, PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2013-04-03
Name of individual signing MAGDALENA KRZYSTOLIK
Valid signature Filed with authorized/valid electronic signature
SOUTHERN NEW ENGLAND RETINA ASSOCIATES RETIREMENT PLAN 2011 203935214 2012-04-17 SOUTHERN NEW ENGLAND RETINA ASSOCIATES, PC 7
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 4014534600
Plan sponsor’s address 1 RANDALL SQUARE, STE 203, PROVIDENCE, RI, 02904

Plan administrator’s name and address
Administrator’s EIN 203935214
Plan administrator’s name SOUTHERN NEW ENGLAND RETINA ASSOCIATES, PC
Plan administrator’s address 1 RANDALL SQUARE, STE 203, PROVIDENCE, RI, 02904
Administrator’s telephone number 4014534600

Signature of
Role Plan administrator
Date 2012-04-17
Name of individual signing MAGDALENA KRZYSTOLIK
Valid signature Filed with authorized/valid electronic signature
SOUTHERN NEW ENGLAND RETINA ASSOCIATES RETIREMENT PLAN 2010 203935214 2011-04-29 SOUTHERN NEW ENGLAND RETINA ASSOCIATES, PC 7
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 4014534600
Plan sponsor’s address 1 RANDALL SQUARE, SUITE 206, PROVIDENCE, RI, 029042709

Plan administrator’s name and address
Administrator’s EIN 203935214
Plan administrator’s name SOUTHERN NEW ENGLAND RETINA ASSOCIATES, PC
Plan administrator’s address 1 RANDALL SQUARE, SUITE 206, PROVIDENCE, RI, 029042709
Administrator’s telephone number 4014534600

Signature of
Role Plan administrator
Date 2011-04-29
Name of individual signing MAGDALENA KRZYSTOLIK
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
ADLER POLLOCK & SHEEHAN P.C. Agent ONE CITIZENS PLAZA 8TH FLOOR, PROVIDENCE, RI, 02903, USA

PRESIDENT

Name Role Address
MAGDALENA G KRZYSTOLIK MD PRESIDENT 386 WAYLAND AVENUE PROVIDENCE, RI 02906 USA

TREASURER

Name Role Address
MAGDALENA G KRZYSTOLIK MD TREASURER 386 WAYLAND AVENUE PROVIDENCE, RI 02906 USA

SECRETARY

Name Role Address
MAGDALENA G KRZYSTOLIK MD SECRETARY 386 WAYLAND AVENUE PROVIDENCE, RI 02906 USA

Events

Type Date Old Value New Value
Name Change 2006-01-13 Retina Associates of Southern New England PC Southern New England Retina Associates PC
Name Change 2005-12-15 Retina Associates of Southeastern New England, Inc. Retina Associates of Southern New England PC

Filings

Number Name File Date
201589503270 Articles of Dissolution 2015-12-21
201555898090 Annual Report 2015-02-27
201433615830 Annual Report 2014-01-17
201310408720 Annual Report 2013-01-28
201289757090 Annual Report 2012-02-17
201175946230 Annual Report 2011-03-02
201058086660 Annual Report 2010-02-08
200941118220 Annual Report 2009-01-29
200806839060 Annual Report 2008-02-14

Related by officers

ADLER POLLOCK & SHEEHAN P.C.

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Related by address

No related companies by address

Date of last update: 09 Oct 2024

Sources: Rhode Island Department of State

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