Basic Information
| Provider Information | |||||||||
| NPI: | 1275655409 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH SHORE MEDICAL CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 LIBBEY INDUSTRIAL PARK | ||||||||
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| City: | WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816825900 | ||||||||
| FaxNumber: | 7813311763 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 WASHNGTON STREET | ||||||||
| Address2: | SOUTH SHORE MEDICAL CENTER, INC | ||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020619147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 12/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | BULMAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | ORTHOPEDIC PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7816825900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 56939 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3014355 | 05 | MA | MEDICAID | 4278730 | 01 | AETNA | OTHER | J05903 | 01 | BCBSMA | OTHER | 0013284 | 01 | NEIGHBORHOOD HEALTH PLAN | OTHER | 171340 | 01 | HARVARD PILGRIM | OTHER | B20290601 | 01 | CIGNA | OTHER | 32150 | 01 | FALLON | OTHER | 729421 | 01 | TUFTS & TUFTS MEDICARE PREFERRED | OTHER |