Basic Information
| Provider Information | |||||||||
| NPI: | 1962881078 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEWARD MEDICAL GROUP, INC | ||||||||
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| OtherOrganizationName: | ENDOSCOPY CENTER OF SOUTHEAST MASS | ||||||||
| 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: | 1 PEARL ST | ||||||||
| Address2: | SUITE 1800 | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023012864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085883174 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2015 | ||||||||
| LastUpdateDate: | 05/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | CLAIRMONT | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF SMG | ||||||||
| AuthorizedOfficialTelephone: | 6174194700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STEWARD HEALTHCARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.