Basic Information
| Provider Information | |||||||||
| NPI: | 1902976798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH SHORE MEDICAL CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 75 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020619147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | HALPIN | ||||||||
| AuthorizedOfficialFirstName: | DETTA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7817924191 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | BS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 9702873 | 05 | MA | MEDICAID | 702028 | 01 | MA | TUFTS | OTHER | M10287 | 01 | MA | BCBSMA | OTHER |