1588659585 NPI number — FAULKNER COMMUNITY MEDICAL CORP

Table of content: (NPI 1588659585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588659585 NPI number — FAULKNER COMMUNITY MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAULKNER COMMUNITY MEDICAL CORP
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:
HYDE PARK MEDICAL CARE
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:
1588659585
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:
1337 HYDE PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HYDE PARK
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02136-2713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-364-9880
Provider Business Mailing Address Fax Number:
617-361-3663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1337 HYDE PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HYDE PARK
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02136-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-364-9880
Provider Business Practice Location Address Fax Number:
617-361-3663
Provider Enumeration Date:
09/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KELEHER
Authorized Official First Name:
JULIANA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
617-364-9880

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 44442 . This is a "AETNA US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0006838 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000029506 . This is a "BOSTON HEALTH NET" identifier . This identifiers is of the category "OTHER".
  • Identifier: CG3305 . This is a "PALMETTO GBA RAILROAD MED" identifier . This identifiers is of the category "OTHER".
  • Identifier: FAM16477 . This is a "BXBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 610235 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9779434 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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