Basic Information
Provider Information | |||||||||
NPI: | 1962437962 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMPASS MEDICAL PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 362 N BEDFORD ST | ||||||||
Address2: |   | ||||||||
City: | EAST BRIDGEWATER | ||||||||
State: | MA | ||||||||
PostalCode: | 023331148 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5083502350 | ||||||||
FaxNumber: | 5083502318 | ||||||||
Practice Location | |||||||||
Address1: | 362 N BEDFORD ST | ||||||||
Address2: |   | ||||||||
City: | EAST BRIDGEWATER | ||||||||
State: | MA | ||||||||
PostalCode: | 023331148 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5083502350 | ||||||||
FaxNumber: | 5083502318 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 10/15/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLAIRMONT | ||||||||
AuthorizedOfficialFirstName: | GEORGE | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5083502350 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | M15549 | 01 | MA | BLUE CROSS & BLUE SHEILD | OTHER | 726355 | 01 | MA | TUFTS | OTHER | 9773282 | 05 | MA |   | MEDICAID |