Healthcare Provider Details

I. General information

NPI: 1336117316
Provider Name (Legal Business Name): RAYNHAM TAUNTON PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

876 BROADWAY
RAYNHAM MA
02767-1797
US

IV. Provider business mailing address

876 BROADWAY
RAYNHAM MA
02767-1797
US

V. Phone/Fax

Practice location:
  • Phone: 508-824-9500
  • Fax: 508-824-9507
Mailing address:
  • Phone: 508-824-9500
  • Fax: 508-824-9507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number52899
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierJ03588
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerBLUE CROSS
# 2
Identifier9702130
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 3
Identifier052899
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerTUFTS
# 4
Identifier2145974
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerAETNA
# 5
IdentifierB10358301
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerCIGNA
# 6
Identifier12-01645
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerUNITED HEALTH CARE
# 7
Identifier200584
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerHARVARD PILGRIM

VIII. Authorized Official

Name: KENNETH ALAN BERLIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 508-824-9500