Provider Demographics
NPI:1114176385
Name:SOUTH EAST CENTER FOR SWALLOWING AND COMMUNICATION DISORDERS, PC
Entity Type:Organization
Organization Name:SOUTH EAST CENTER FOR SWALLOWING AND COMMUNICATION DISORDERS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:MS-CCC-SLP
Authorized Official - Phone:508-991-2332
Mailing Address - Street 1:92 GRAPE ST
Mailing Address - Street 2:UNIT 1
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-2143
Mailing Address - Country:US
Mailing Address - Phone:508-991-2332
Mailing Address - Fax:508-991-8437
Practice Address - Street 1:92 GRAPE ST
Practice Address - Street 2:UNIT 1
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-2143
Practice Address - Country:US
Practice Address - Phone:508-991-2332
Practice Address - Fax:508-991-8437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9737570Medicaid
MA9737570Medicaid