Basic Information
| Provider Information | |||||||||
| NPI: | 1386753556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 370 FOUNCE CORNER ROAD | ||||||||
| Address2: | SOUTHCOAST PHYSICIAN SERVICES, INC. | ||||||||
| City: | NO. DARTMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089852000 | ||||||||
| FaxNumber: | 5089852001 | ||||||||
| Practice Location | |||||||||
| Address1: | 43 HIGH STREET | ||||||||
| Address2: | SOUTHCOAST PHYSICIAN SERVICES, INC. | ||||||||
| City: | WAREHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089615919 | ||||||||
| FaxNumber: | 5089615916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 12/17/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 44626 | MA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208M00000X | 44626 | MA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | J02275 | 01 | MA | BCBSMA | OTHER | 2090686 | 05 | MA | MEDICAID |