Provider Demographics
NPI:1336137629
Name:SOUTHCOAST PHYSICIANS GROUP, INC.
Entity Type:Organization
Organization Name:SOUTHCOAST PHYSICIANS GROUP, INC.
Other - Org Name:SOUTHCOAST PHYSICIAN SERVICES, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SHS VICE PRESIDENT OF CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-973-2950
Mailing Address - Street 1:200 MILL ROAD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:200 MILL ROAD
Practice Address - Street 2:SUITE 180
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-5252
Practice Address - Country:US
Practice Address - Phone:508-973-2000
Practice Address - Fax:508-973-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MACN5678OtherRAILROAD MEDICARE
MAM20518OtherMEDICARE PIN
RIBM20689Medicaid
MACD2506OtherRAILROAD MEDICARE
MACG4450OtherRAILROAD MEDICARE
MA9779752Medicaid
MAM16989OtherBCBS MASSACHUSETTS
RISP28498Medicaid
RIBM11666Medicaid
RISP28498Medicaid
RI709004034Medicare PIN
MAM20554Medicare PIN
MACD2506OtherRAILROAD MEDICARE