Healthcare Provider Details

I. General information

NPI: 1851773584
Provider Name (Legal Business Name): PLYMOUTH PEDIATRIC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 07/15/2024
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 INDUSTRIAL PARK RD
PLYMOUTH MA
02360-7243
US

IV. Provider business mailing address

148 INDUSTRIAL PARK RD
PLYMOUTH MA
02360-7243
US

V. Phone/Fax

Practice location:
  • Phone: 508-747-5900
  • Fax: 508-747-2290
Mailing address:
  • Phone: 508-747-5900
  • Fax: 508-747-2290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSICA WALSH
Title or Position: MANAGING MEMBER
Credential: D.O.
Phone: 508-747-5900