Basic Information
| Provider Information | |||||||||
| NPI: | 1043299001 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETH ISRAEL DEACONESS HOSPITAL PLYMOUTH, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 SANDWICH ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087462000 | ||||||||
| FaxNumber: | 5088301131 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 SANDWICH ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087462000 | ||||||||
| FaxNumber: | 5088301131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | RADZEVICH | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | V.P. OF FINANCE AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 5088302005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 2082 | MA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 2222006001 | 01 | MA | BCBS MA INPATIENT | OTHER | 110024453C | 05 | MA | MEDICAID | 000000020545 | 01 | MA | BMC HEALTHNET | OTHER | 220060 | 01 | MA | MEDICARE PTAN | OTHER | 1001434 | 05 | MA | MEDICAID | 500444 | 01 | MA | TUFTS 1500 PSYCH BILLING | OTHER | 900002 | 01 | MA | HPHC | OTHER | S012236 | 01 | MA | CHAMPUS | OTHER | 900021 | 01 | MA | TUFTS INPATIENT | OTHER |