1003038365 NPI number — MA DEPARTMENT OF YOUTH SERVICES

Table of content: (NPI 1003038365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003038365 NPI number — MA DEPARTMENT OF YOUTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MA DEPARTMENT OF YOUTH SERVICES
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:
1003038365
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27 WORMWOOD STREET
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-727-7575
Provider Business Mailing Address Fax Number:
617-951-2409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27 WORMWOOD STREET
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-727-7575
Provider Business Practice Location Address Fax Number:
617-951-2409
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EGAN
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
BUDGET DIRECTOR
Authorized Official Telephone Number:
617-960-3258

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1803867 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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