Provider Demographics
NPI:1629177597
Name:BREAST CENTER OF SOUTH COAST, LLC
Entity Type:Organization
Organization Name:BREAST CENTER OF SOUTH COAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-990-2220
Mailing Address - Street 1:690 CANTON ST
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090-2321
Mailing Address - Country:US
Mailing Address - Phone:781-407-7713
Mailing Address - Fax:781-407-0998
Practice Address - Street 1:52 BRIGHAM ST
Practice Address - Street 2:SUITE 3
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-2210
Practice Address - Country:US
Practice Address - Phone:508-990-2220
Practice Address - Fax:508-994-9628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM21669Medicare PIN
MAG10960Medicare UPIN