1720112592 NPI number — MGH FAMILY CARE PROGRAM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720112592 NPI number — MGH FAMILY CARE PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MGH FAMILY CARE PROGRAM
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:
6
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:
1720112592
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32 FRUIT ST
Provider Second Line Business Mailing Address:
WACC LOBBY 037
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02114-2620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-724-0759
Provider Business Mailing Address Fax Number:
617-726-7676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32 FRUIT ST
Provider Second Line Business Practice Location Address:
WACC LOBBY 037
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114-2620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-724-0759
Provider Business Practice Location Address Fax Number:
617-726-7676
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DANIELS
Authorized Official First Name:
ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXEC. DIRECTOR OF SOCIAL SERVICE
Authorized Official Telephone Number:
617-726-2657

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1904191 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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