1336137629 NPI number — SOUTHCOAST PHYSICIANS GROUP, INC.

Table of content: (NPI 1336137629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336137629 NPI number — SOUTHCOAST PHYSICIANS GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHCOAST PHYSICIANS GROUP, 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:
Provider Other Organization Name Type Code:
6
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:
1336137629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 MILL ROAD
Provider Second Line Business Mailing Address:
SUITE 180
Provider Business Mailing Address City Name:
FAIRHAVEN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02719-5252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-973-2000
Provider Business Mailing Address Fax Number:
508-973-2001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 MILL ROAD
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
FAIRHAVEN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02719-5252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-973-2000
Provider Business Practice Location Address Fax Number:
508-973-2001
Provider Enumeration Date:
10/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROSE
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
SHS VICE PRESIDENT OF CONTRACTING
Authorized Official Telephone Number:
508-973-2950

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CN5678 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M20518 . This is a "MEDICARE PIN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: BM20689 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD2506 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: CG4450 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9779752 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M16989 . This is a "BCBS MASSACHUSETTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: SP28498 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: BM11666 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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