Provider Demographics
NPI:1215987300
Name:BROCKTON MEDICAL CENTER
Entity type:Organization
Organization Name:BROCKTON MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:508-580-1001
Mailing Address - Street 1:90 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4011
Mailing Address - Country:US
Mailing Address - Phone:508-580-1001
Mailing Address - Fax:508-580-2002
Practice Address - Street 1:90 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4011
Practice Address - Country:US
Practice Address - Phone:508-580-1001
Practice Address - Fax:508-580-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1919111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY45008Medicare ID - Type Unspecified