1275782435 NPI number — SOUTH SHORE PHYSIATRY AND SPASTICITY MANAGEMENT

Table of content: (NPI 1275782435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275782435 NPI number — SOUTH SHORE PHYSIATRY AND SPASTICITY MANAGEMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH SHORE PHYSIATRY AND SPASTICITY MANAGEMENT
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:
Provider Other Organization Name Type Code:
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:
1275782435
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
132 ISLAND CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUXBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02332-4323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-448-9303
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 POND STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRAINTREE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02184-5351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-348-2202
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KOELBEL
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
617-448-9303

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M19641 . This is a "BLUE CROSS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 110083193A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com