Healthcare Provider Details

I. General information

NPI: 1336137629
Provider Name (Legal Business Name): SOUTHCOAST PHYSICIANS GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MILL ROAD SUITE 180
FAIRHAVEN MA
02719-5252
US

IV. Provider business mailing address

200 MILL ROAD SUITE 180
FAIRHAVEN MA
02719-5252
US

V. Phone/Fax

Practice location:
  • Phone: 508-973-2000
  • Fax: 508-973-2001
Mailing address:
  • Phone: 508-973-2000
  • Fax: 508-973-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA ROSE
Title or Position: SHS VICE PRESIDENT OF CONTRACTING
Credential:
Phone: 508-973-2950