Provider Demographics
NPI:1134126105
Name:SWERIDUK, STEPHEN T (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:T
Last Name:SWERIDUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 WESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1817
Mailing Address - Country:US
Mailing Address - Phone:800-258-4674
Mailing Address - Fax:508-897-3198
Practice Address - Street 1:265 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1817
Practice Address - Country:US
Practice Address - Phone:800-258-4674
Practice Address - Fax:508-897-3198
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA577932085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ06212OtherBLUE CROSS BLUE SHIELD
MA3020266Medicaid
J06212Medicare ID - Type Unspecified
MAJ06212OtherBLUE CROSS BLUE SHIELD