Basic Information
| Provider Information | |||||||||
| NPI: | 1104829423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLDERSHAW | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | HALLOCK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2527 CRANBERRY HIGHWAY | ||||||||
| Address2: | ATTN: NANCI KARDOS-CARLL/PROVIDER RELATIONS DEPT. | ||||||||
| City: | WAREHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025711046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008415200 | ||||||||
| FaxNumber: | 5082731241 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 HERRICK ST | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019151776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789223000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 07/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 72783 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3070786 | 05 | MA | MEDICAID |