Healthcare Provider Details

I. General information

NPI: 1134126105
Provider Name (Legal Business Name): STEPHEN T SWERIDUK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 12/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 WESTGATE DR
BROCKTON MA
02301-1817
US

IV. Provider business mailing address

265 WESTGATE DR
BROCKTON MA
02301-1817
US

V. Phone/Fax

Practice location:
  • Phone: 800-258-4674
  • Fax: 508-897-3198
Mailing address:
  • Phone: 800-258-4674
  • Fax: 508-897-3198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number57793
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number57793
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: