1154600344 NPI number — EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC

Table of content: (NPI 1154600344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154600344 NPI number — EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GREAT BROOK VALLEY HEALTH CENTER
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154600344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 NE CUTOFF STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01606-1224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-854-2122
Provider Business Mailing Address Fax Number:
508-853-8593

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
354 WAVERLY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRAMINGHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01702-7079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-370-0113
Provider Business Practice Location Address Fax Number:
508-370-3637
Provider Enumeration Date:
08/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KERRIGAN
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
508-854-2122

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110022061E , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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