1609842152 NPI number — EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC

Table of content: (NPI 1609842152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609842152 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, INC
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:
1609842152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2023
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:
19 TACOMA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01605-3516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-852-1805
Provider Business Practice Location Address Fax Number:
508-854-3248
Provider Enumeration Date:
02/24/2006

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 , with the licence number:  4039 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0443891 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1301071 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110022061B , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1320858 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Y10100 . This is a "BCBS OF MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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