Provider Demographics
NPI:1861830143
Name:SOUTHCOAST PHYSICIANS GROUP, INC.
Entity Type:Organization
Organization Name:SOUTHCOAST PHYSICIANS GROUP, INC.
Other - Org Name:SOUTHCOAST URGENT CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, CBO
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIZZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-973-2044
Mailing Address - Street 1:200 MILL RD
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 1:208 MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-5208
Practice Address - Country:US
Practice Address - Phone:855-319-0518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-10
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 207Q00000X, 207R00000X, 208000000X, 208M00000X, 261QU0200X
MA261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110072422AMedicaid
RIBM20689Medicaid
RIDT1369OtherRAILROAD MEDICARE
MACD2506OtherRAILROAD MEDICARE
RI709004034Medicare PIN
MAM20518Medicare PIN