Provider Demographics
NPI:1861501835
Name:ENDOSCOPY CENTER OF SOUTHEAST MASSACHUSETTS LLC
Entity Type:Organization
Organization Name:ENDOSCOPY CENTER OF SOUTHEAST MASSACHUSETTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-588-3174
Mailing Address - Street 1:1 PEARL ST
Mailing Address - Street 2:ST 1800
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-2864
Mailing Address - Country:US
Mailing Address - Phone:508-588-3174
Mailing Address - Fax:508-588-3179
Practice Address - Street 1:1 PEARL ST
Practice Address - Street 2:ST 1200
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2864
Practice Address - Country:US
Practice Address - Phone:508-588-3174
Practice Address - Fax:508-588-3179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA63138261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA221046Medicare ID - Type Unspecified