1417161712 NPI number — CAMBRIDGE HEALTH ALLIANCE PHYSICIANS ORGANIZATION

Table of content: (NPI 1417161712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417161712 NPI number — CAMBRIDGE HEALTH ALLIANCE PHYSICIANS ORGANIZATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAMBRIDGE HEALTH ALLIANCE PHYSICIANS ORGANIZATION
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:
Provider Other Organization Name Type Code:
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:
1417161712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1493 CAMBRIDGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02139-1047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-665-1000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1493 CAMBRIDGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02139-1047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-665-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PORELL
Authorized Official First Name:
DAVE
Authorized Official Middle Name:
Authorized Official Title or Position:
CAO
Authorized Official Telephone Number:
617-499-6621

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2081H0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 9779159 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9779043 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M15404 . This is a "BCBS LEGACY GROUP NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M18077 . This is a "BCBS LEGACY GROUP NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".