Basic Information
| Provider Information | |||||||||
| NPI: | 1093770059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAILLANCOURT | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 PRESIDENT AVE | ||||||||
| Address2: | SUITE 104 SOUTHCOAST PHYSICIAN SERVICES INC | ||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027205923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086763411 | ||||||||
| FaxNumber: | 5082356656 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 PRESIDENT AVE | ||||||||
| Address2: | SUITE 104 SOUTHCOAST PHYSICIAN SERVICES INC | ||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027205923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086763411 | ||||||||
| FaxNumber: | 5082356656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 42866 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0000025599 | 01 | RI | BLUE SHIELD | OTHER | 60417 | 01 | MA | HARVARD PILGRIM | OTHER | B10491301 | 01 | MA | CIGNA | OTHER | 004393 | 01 | RI | BLUE CHIP | OTHER | 000000021256 | 01 | MA | BMC HEALTHNET | OTHER | 2069199 | 05 | MA | MEDICAID | K08341 | 01 | MA | BLUE SHIELD | OTHER | 0101462 | 01 | MA | UNITED HEALTHCARE | OTHER | 764242 | 01 | MA | TUFTS | OTHER | 0016215 | 01 | MA | NEIGHBORHOOD HEALTHPLAN | OTHER | 3684748 | 01 | MA | HEALTHSOURCE | OTHER |