Basic Information
| Provider Information | |||||||||
| NPI: | 1770504599 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROCKTON HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SIGNATURE HEALTHCARE BROCKTON HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847493 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022847493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417555 | ||||||||
| FaxNumber: | 5089416303 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOLLON | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5089417004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 2118 | MA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1200283 | 05 | MA | MEDICAID | 1002112 | 05 | MA | MEDICAID | M18952 | 01 | MA | BCBS GROUP # | OTHER |