Provider Demographics
NPI:1962686329
Name:BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES PODIATRY DIVISION
Entity Type:Organization
Organization Name:BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES PODIATRY DIVISION
Other - Org Name:SIGNATURE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-941-7004
Mailing Address - Street 1:110 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5521
Mailing Address - Country:US
Mailing Address - Phone:508-894-0400
Mailing Address - Fax:508-565-0157
Practice Address - Street 1:110 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5521
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:508-565-0157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1715213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110022141EMedicaid
MAM20452Medicare PIN