Basic Information
Provider Information | |||||||||
NPI: | 1063431286 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BROCKTON HOSPITAL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SIGNATURE HEALTHCARE BROCKTON HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 680 CENTRE ST | ||||||||
Address2: |   | ||||||||
City: | BROCKTON | ||||||||
State: | MA | ||||||||
PostalCode: | 023023395 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5089417555 | ||||||||
FaxNumber: | 5089416303 | ||||||||
Practice Location | |||||||||
Address1: | 680 CENTRE ST | ||||||||
Address2: |   | ||||||||
City: | BROCKTON | ||||||||
State: | MA | ||||||||
PostalCode: | 023023308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5089417000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 03/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOLLON | ||||||||
AuthorizedOfficialFirstName: | KIM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5089417004 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 2118 | MA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | M15998 | 01 | MA | BCBS GROUP | OTHER | 110026502B | 05 | MA |   | MEDICAID | 110026502C | 05 | MA |   | MEDICAID |