| Name: | JENNIFER SOUTHER MD, INC. |
| Jurisdiction: | Rhode Island |
| Entity type: | Professional Service Corporation |
| Status: | Revoked Entity |
| Date of Organization in Rhode Island: | 17 Jan 2007 (18 years ago) |
| Date of Dissolution: | 12 Dec 2011 (13 years ago) |
| Date of Status Change: | 12 Dec 2011 (13 years ago) |
| Identification Number: | 000161063 |
| ZIP code: | 02886 |
| County: | Kent County |
| Principal Address: | JOS. FAMIGLIETTI C/O 117 METRO CENTER BOULEVARD-2008, WARWICK, RI, 02886, USA |
| Purpose: | MEDICAL |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1346394616 | 2007-01-23 | 2020-08-22 | 30 MARTIN ST, UNIT 30A, CUMBERLAND, RI, 028645321, US | 30 MARTIN ST, UNIT 30A, CUMBERLAND, RI, 028645321, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Phone | +1 401-334-4500 |
| Fax | 4013120096 |
Authorized person
| Name | MS. CARYN RUSSO |
| Role | OFFICE MANAGER |
| Phone | 4013344500 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | MD10848 |
| State | RI |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | UNITED HEALTH CARE |
| Number | 01-02493 |
| State | RI |
| Issuer | BLUE CROSS |
| Number | 32087-4 |
| State | RI |
| Issuer | BLUE CHIP OF RI |
| Number | 409677 |
| State | RI |
| Issuer | MULTIPLAN |
| Number | 12001018 |
| State | RI |
| Issuer | LIC |
| Number | MD10848 |
| State | RI |
| Issuer | HARVARD PILGRIM |
| Number | AA242 |
| State | RI |
| Name | Role | Address |
|---|---|---|
| JOSEPH M. FAMIGLIETTI | Agent | 117 METRO CENTER BOULEVARD, WARWICK, RI, 02886, USA |
| Name | Role | Address |
|---|---|---|
| JENNIFER SOUTHER | PRESIDENT | 30A MARTIN STREET CUMBERLAND , RI 02864 USA |
| Number | Name | File Date |
|---|---|---|
| 201187021130 | Revocation Certificate For Failure to File the Annual Report for the Year | 2011-12-12 |
| 201182542810 | Revocation Notice For Failure to File An Annual Report | 2011-09-13 |
| 201056194600 | Annual Report | 2010-01-11 |
| 200941180470 | Statement of Change of Registered Office by the Registered Agent | 2009-01-30 |
| 200941220400 | Annual Report | 2009-01-26 |
| 200940750430 | Revocation Notice For Failure to Maintain a Registered Office | 2009-01-23 |
| 200940704730 | Registered Office Not Maintained | 2009-01-05 |
| 200806231800 | Annual Report | 2008-01-22 |
Date of last update: 10 Oct 2024
Sources: Rhode Island Department of State
