Provider Demographics
NPI:1043299001
Name:BETH ISRAEL DEACONESS HOSPITAL PLYMOUTH, INC.
Entity Type:Organization
Organization Name:BETH ISRAEL DEACONESS HOSPITAL PLYMOUTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. OF FINANCE AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:M
Authorized Official - Last Name:RADZEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-830-2005
Mailing Address - Street 1:275 SANDWICH ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2183
Mailing Address - Country:US
Mailing Address - Phone:508-746-2000
Mailing Address - Fax:508-830-1131
Practice Address - Street 1:275 SANDWICH ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2183
Practice Address - Country:US
Practice Address - Phone:508-746-2000
Practice Address - Fax:508-830-1131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2082282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2222006001OtherBCBS MA INPATIENT
MA110024453CMedicaid
MA000000020545OtherBMC HEALTHNET
MA220060OtherMEDICARE PTAN
MA1001434Medicaid
MA500444OtherTUFTS 1500 PSYCH BILLING
MA900002OtherHPHC
MAS012236OtherCHAMPUS
MA900021OtherTUFTS INPATIENT