Basic Information
| Provider Information | |||||||||
| NPI: | 1851346746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAPE COD EMERGENCY ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 OAK PARK DR | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017301414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812801683 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27 PARK ST | ||||||||
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| City: | HYANNIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026015230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088625981 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 01/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | CORNWALL | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OF ER DEPT | ||||||||
| AuthorizedOfficialTelephone: | 5088625981 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | CH7855 | 01 | MA | MEDICARE/TRAVELERS | OTHER | M17425 | 01 | MA | BCBS | OTHER | 110067342A | 05 | MA | MEDICAID |