Basic Information
| Provider Information | |||||||||
| NPI: | 1164535084 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETH ISRAEL DEACONESS HOSPITAL PLYMOUTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRANBERRY HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 36 CORDAGE PARK CIR | ||||||||
| Address2: | SUITE 326 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023607331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087460215 | ||||||||
| FaxNumber: | 5088303336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RADZEVICH | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | V.P. OF FINANCE AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 5088302005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 7221 | MA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 0608556 | 05 | MA | MEDICAID | 221520 | 01 | MA | BCBS MA CRANBERRY HOSPICE | OTHER | S012236 | 01 | MA | CHAMPUS | OTHER | 000000020545 | 01 | MA | BMC HEALTHNET | OTHER | 819809 | 01 | MA | TUFTS CRANBERRY HOSP-2 | OTHER | 221520B | 01 | MA | MEDICARE PTAN CRANBERRY HOSPICE | OTHER | AA50951 | 01 | MA | HPHC CRANBERRY HOSPICE | OTHER |