1255376588 NPI number — GOOD SAMARITAN HOSPICE

Table of content: (NPI 1255376588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255376588 NPI number — GOOD SAMARITAN HOSPICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOD SAMARITAN HOSPICE
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:
CARITAS GOOD SAMARITAN HOSPICE
Provider Other Organization Name Type Code:
3
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:
1255376588
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:
310 ALLSTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02135-7659
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-566-6242
Provider Business Mailing Address Fax Number:
617-566-3055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 ALLSTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02135-7659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-566-6242
Provider Business Practice Location Address Fax Number:
617-566-3055
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
LEO
Authorized Official Middle Name:
P
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
617-566-6242

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  7218 , 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: 702185 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0604658 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 800943 . This is a "TUFTS HEALTH PLAN FO MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 224518 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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