Basic Information
| Provider Information | |||||||||
| NPI: | 1295798122 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARK SURGICAL ASSOCIATES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PEARL STREET | ||||||||
| Address2: | STE 2700 | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023012870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085844104 | ||||||||
| FaxNumber: | 5085844106 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PEARL STREET | ||||||||
| Address2: | STE 2700 | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023012870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085844104 | ||||||||
| FaxNumber: | 5085844105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| AuthorizedOfficialLastName: | COREY | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5085844104 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0007011 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | DB2012 | 01 | MA | RR MEDICARE | OTHER | 600325 | 01 | MA | SECURE HORIZONS | OTHER | 9704043 | 05 | MA | MEDICAID | 600325 | 01 | MA | TUFTS | OTHER | 97320 | 01 | MA | AETNA | OTHER |