1104874874 NPI number — SOUTHCOAST PHYSICIAN SERVICES INC

Table of content: (NPI 1104874874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104874874 NPI number — SOUTHCOAST PHYSICIAN SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHCOAST PHYSICIAN SERVICES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TRUESDALE MEDICAL SPECIALTIES ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104874874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1030 PRESIDENT AVE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
FALL RIVER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02720-5923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-676-3411
Provider Business Mailing Address Fax Number:
508-235-6656

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1030 PRESIDENT AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
FALL RIVER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02720-5923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-676-3411
Provider Business Practice Location Address Fax Number:
508-235-6656
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HODGSON
Authorized Official First Name:
MARY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
508-985-2011

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9704876 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M17689 . This is a "BC BS OF MASS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 004236 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: B10187907 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0000025599 . This is a "BC BS OF RI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 0021912 . This is a "NEIGHBORHOOD HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000021264 . This is a "BMC HEALTHNET" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 44108 . This is a "AETNA US HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 620388 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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