Basic Information
| Provider Information | |||||||||
| NPI: | 1891783189 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHCOAST PRIMARY CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 370 FAUNCE CORNER RD | ||||||||
| Address2: | SOUTHCOAST PRIMARY CARE INC | ||||||||
| City: | NORTH DARTMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089852000 | ||||||||
| FaxNumber: | 5089852001 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 FAIRHAVEN ROAD | ||||||||
| Address2: | SOUTHCOAST PRIMARY CARE INC | ||||||||
| City: | MATTAPOISETT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087583781 | ||||||||
| FaxNumber: | 5087584455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | HODGSON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5089852011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CE9725 | 01 | MA | RAILROAD MEDICARE | OTHER | 9782036 | 05 | MA | MEDICAID | M16797 | 01 | MA | BCBS MASSACHUSETTS | OTHER |