Healthcare Provider Details

I. General information

NPI: 1417932591
Provider Name (Legal Business Name): BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LIBERTY ST
BROCKTON MA
02301-5521
US

IV. Provider business mailing address

110 LIBERTY ST
BROCKTON MA
02301-5521
US

V. Phone/Fax

Practice location:
  • Phone: 508-894-0400
  • Fax: 508-565-0157
Mailing address:
  • Phone: 508-894-0400
  • Fax: 508-565-0157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KIM HOLLON
Title or Position: CEO
Credential:
Phone: 508-941-7004