Provider Demographics
NPI:1114948478
Name:SOUTH SUBURBAN GASTROENTEROLOGY, PC
Entity Type:Organization
Organization Name:SOUTH SUBURBAN GASTROENTEROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-331-2922
Mailing Address - Street 1:1085 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1547
Mailing Address - Country:US
Mailing Address - Phone:781-331-2922
Mailing Address - Fax:781-335-5702
Practice Address - Street 1:1085 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1547
Practice Address - Country:US
Practice Address - Phone:781-331-2922
Practice Address - Fax:781-335-5702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9768882Medicaid
MA9768882Medicaid