1053463448 NPI number — THE COMMONWEALTH OF MASSACHUSETTS

Table of content: (NPI 1053463448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053463448 NPI number — THE COMMONWEALTH OF MASSACHUSETTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE COMMONWEALTH OF MASSACHUSETTS
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:
1053463448
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 SOUTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02130-3515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-983-6668
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 SOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02130-3515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-983-6668
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DUNN
Authorized Official First Name:
CECILIA
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
DEPUTY DIRECTOR
Authorized Official Telephone Number:
617-963-6413

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  NA , 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: 800470 . This is a "HEALTH PILGRIM HEALTH PLA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0805998 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 804460 . This is a "TUFTS HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: BOSTON HEALTHNET . This is a "20611" identifier . This identifiers is of the category "OTHER".
  • Identifier: 32545 . This is a "CHILDRENS MEDICAL SECURIT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 228421 . This is a "BLUE CROSS OF MASS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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