Basic Information
| Provider Information | |||||||||
| NPI: | 1114160553 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEASHORE POINT - DEACONESS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 100 ALDEN ST | ||||||||
| Address2: | |||||||||
| City: | PROVINCETOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026571456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084877090 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 ALDEN ST | ||||||||
| Address2: | |||||||||
| City: | PROVINCETOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026571456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084877090 | ||||||||
| FaxNumber: | 5084877706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2009 | ||||||||
| LastUpdateDate: | 04/15/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLARUSSO | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5084877090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NEW ENGLAND DEACONESS ASSOCIATION INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X | 0849 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine |
No ID Information.