Basic Information
| Provider Information | |||||||||
| NPI: | 1497956254 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHCOAST PHYSICIAN SERVICES, INC. | ||||||||
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| OtherOrganizationName: | WAREHAM SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 370 FAUNCE CORNER RD | ||||||||
| Address2: | SOUTHCOAST PHYSICIAN SERVICES, INC. | ||||||||
| City: | N DARTMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027471271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089852000 | ||||||||
| FaxNumber: | 5089852001 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 MAIN ST | ||||||||
| Address2: | SOUTHCOAST PHYSICIAN SERVICES, INC DBA WAREHAM SURGICAL | ||||||||
| City: | WAREHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025712122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082953900 | ||||||||
| FaxNumber: | 5082953271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | KRUGER | ||||||||
| AuthorizedOfficialFirstName: | RAYFORD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5082953900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHCOAST PHYSICIAN SERVICES, INC. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.