Provider Demographics
NPI:1336117316
Name:RAYNHAM TAUNTON PEDIATRICS
Entity Type:Organization
Organization Name:RAYNHAM TAUNTON PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-824-9500
Mailing Address - Street 1:876 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1797
Mailing Address - Country:US
Mailing Address - Phone:508-824-9500
Mailing Address - Fax:508-824-9507
Practice Address - Street 1:876 BROADWAY
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1797
Practice Address - Country:US
Practice Address - Phone:508-824-9500
Practice Address - Fax:508-824-9507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52899208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDJ03588OtherBLUE CROSS
MA9702130Medicaid
MA052899OtherTUFTS
MA2145974OtherAETNA
MAB10358301OtherCIGNA
MA12-01645OtherUNITED HEALTH CARE
MA200584OtherHARVARD PILGRIM
MA12-01645OtherUNITED HEALTH CARE