Provider Demographics
NPI: | 1508804949 |
---|---|
Name: | SIGNATURE HEALTHCARE MEDICAL GROUP, INC. |
Entity Type: | Organization |
Organization Name: | SIGNATURE HEALTHCARE MEDICAL GROUP, INC. |
Other - Org Name: | SIGNATURE MEDICAL |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | DIRECTOR, MANAGED CARE |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CYNTHIA |
Authorized Official - Middle Name: | MARIE |
Authorized Official - Last Name: | COLBY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 508-941-0958 |
Mailing Address - Street 1: | 680 CENTRE ST |
Mailing Address - Street 2: | |
Mailing Address - City: | BROCKTON |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02302-3308 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 508-894-0400 |
Mailing Address - Fax: | 508-941-0893 |
Practice Address - Street 1: | 680 CENTRE ST |
Practice Address - Street 2: | |
Practice Address - City: | BROCKTON |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02302-3308 |
Practice Address - Country: | US |
Practice Address - Phone: | 508-941-7000 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-06-04 |
Last Update Date: | 2023-09-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
104100000X, 207RC0000X, 207RE0101X, 207RG0100X, 207RN0300X, 207RP1001X, 207V00000X, 207X00000X, 208000000X, 2084P0800X, 208600000X, 208800000X, 208M00000X | ||
MA | 240642 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | 110072349A | Medicaid | |
MA | M16402 | Other | BCBS GROUP # |
MA | M20191 | Medicare PIN |