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General NPI Number Information
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NPI Number | 1417932591
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Entity Type | Organization
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Legal Business Name | BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES, INC.
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Dates
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Enumeration Date | 12/12/2005
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Last Update Date | 06/18/2013
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Provider Practice Location Address
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Address Line | 110 LIBERTY ST
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City | BROCKTON
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State | MA
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Zip | 02301-5521
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Country | US
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Telephone | 508-894-0400
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Fax | 508-565-0157
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Provider Business Mailing Address
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Address Line | 110 LIBERTY ST
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City | BROCKTON
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State | MA
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Zip | 02301-5521
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Country | US
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Telephone | 508-894-0400
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Fax | 508-565-0157
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Authorized Official
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Title or Position | CEO
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Name | MR. KIM HOLLON
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Credential |
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Telephone | 508-941-7004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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