Basic Information
| Provider Information | |||||||||
| NPI: | 1821349317 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEWARD MEDICAL GROUP, INC | ||||||||
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| OtherOrganizationName: | SMG HAWTHORN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 BOYLSTON ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021163740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174194700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 535 FAUNCE CORNER RD | ||||||||
| Address2: | |||||||||
| City: | DARTMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027471242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174194700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2012 | ||||||||
| LastUpdateDate: | 09/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | CALLUM | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SMG CEO | ||||||||
| AuthorizedOfficialTelephone: | 6174194702 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STEWARD HEALTH CARE SYSTEM, LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.