Provider Demographics
NPI:1164535084
Name:BETH ISRAEL DEACONESS HOSPITAL PLYMOUTH, INC.
Entity Type:Organization
Organization Name:BETH ISRAEL DEACONESS HOSPITAL PLYMOUTH, INC.
Other - Org Name:CRANBERRY HOSPICE
Other - Org Type:Doing Business As
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 1:36 CORDAGE PARK CIR
Practice Address - Street 2:SUITE 326
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-7331
Practice Address - Country:US
Practice Address - Phone:508-746-0215
Practice Address - Fax:508-830-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7221251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0608556Medicaid
MA221520OtherBCBS MA CRANBERRY HOSPICE
MAS012236OtherCHAMPUS
MA000000020545OtherBMC HEALTHNET
MA819809OtherTUFTS CRANBERRY HOSP-2
MA221520BOtherMEDICARE PTAN CRANBERRY HOSPICE
MAAA50951OtherHPHC CRANBERRY HOSPICE
MA819809OtherTUFTS CRANBERRY HOSP-2