Provider Demographics
NPI:1093770059
Name:VAILLANCOURT, HENRY R (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:R
Last Name:VAILLANCOURT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1030 PRESIDENT AVE
Mailing Address - Street 2:SUITE 104 SOUTHCOAST PHYSICIAN SERVICES INC
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-5923
Mailing Address - Country:US
Mailing Address - Phone:508-676-3411
Mailing Address - Fax:508-235-6656
Practice Address - Street 1:1030 PRESIDENT AVE
Practice Address - Street 2:SUITE 104 SOUTHCOAST PHYSICIAN SERVICES INC
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5923
Practice Address - Country:US
Practice Address - Phone:508-676-3411
Practice Address - Fax:508-235-6656
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2007-07-09
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA42866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0000025599OtherBLUE SHIELD
MA60417OtherHARVARD PILGRIM
MAB10491301OtherCIGNA
RI004393OtherBLUE CHIP
MA000000021256OtherBMC HEALTHNET
MA2069199Medicaid
MAK08341OtherBLUE SHIELD
MA0101462OtherUNITED HEALTHCARE
MA764242OtherTUFTS
MA0016215OtherNEIGHBORHOOD HEALTHPLAN
MA3684748OtherHEALTHSOURCE
RI004393OtherBLUE CHIP
MA3684748OtherHEALTHSOURCE