Provider Demographics
NPI:1417932591
Name:BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES, INC.
Entity type:Organization
Organization Name:BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-941-7004
Mailing Address - Street 1:110 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5521
Mailing Address - Country:US
Mailing Address - Phone:508-894-0400
Mailing Address - Fax:508-565-0157
Practice Address - Street 1:110 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5521
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:508-565-0157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-12
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110022141EMedicaid
MAM20452Medicare PIN
MA110022141EMedicaid