Basic Information
| Provider Information | |||||||||
| NPI: | 1104874874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHCOAST PHYSICIAN SERVICES INC | ||||||||
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| OtherOrganizationName: | TRUESDALE MEDICAL SPECIALTIES ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 PRESIDENT AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027205923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086763411 | ||||||||
| FaxNumber: | 5082356656 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 PRESIDENT AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027205923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086763411 | ||||||||
| FaxNumber: | 5082356656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HODGSON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5089852011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9704876 | 05 | MA | MEDICAID | M17689 | 01 | MA | BC BS OF MASS | OTHER | 004236 | 01 | RI | BLUE CHIP | OTHER | B10187907 | 01 | MA | CIGNA | OTHER | 0000025599 | 01 | RI | BC BS OF RI | OTHER | 0021912 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 000000021264 | 01 | MA | BMC HEALTHNET | OTHER | 44108 | 01 | MA | AETNA US HEALTHCARE | OTHER | 620388 | 01 | MA | TUFTS | OTHER |