Basic Information
| Provider Information | |||||||||
| NPI: | 1497867923 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROCKTON RADIOLOGICAL ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417150 | ||||||||
| FaxNumber: | 5089416104 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417150 | ||||||||
| FaxNumber: | 5089416104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SALZMAN | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5089417150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 9745254 | 05 | MA | MEDICAID |