Provider Demographics
NPI:1861607558
Name:BETHEL MEDICAL GROUP PC
Entity type:Organization
Organization Name:BETHEL MEDICAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:GROGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-588-1200
Mailing Address - Street 1:PO BOX 848889
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8889
Mailing Address - Country:US
Mailing Address - Phone:508-588-1200
Mailing Address - Fax:508-941-0497
Practice Address - Street 1:111 TORREY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4800
Practice Address - Country:US
Practice Address - Phone:508-588-1200
Practice Address - Fax:508-941-0497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9780629Medicaid