Basic Information
| Provider Information | |||||||||
| NPI: | 1285625137 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD SAMARITAN MEDICAL PRACTICE CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 WARREN ST | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175625482 | ||||||||
| FaxNumber: | 6175625415 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 N PEARL ST | ||||||||
| Address2: | GOOD SAMARITAN MEDICAL CENTER | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023011794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175625482 | ||||||||
| FaxNumber: | 6175625415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOLIVER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6175625482 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 9779213 | 05 | MA | MEDICAID |