Basic Information
| Provider Information | |||||||||
| NPI: | 1023148590 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARITAS CARNEY HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 DORCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | DORCHESTER CENTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021245615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172964000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2100 DORCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | DORCHESTER CENTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021245615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172964000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 06/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | TREMBLAY | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6172964000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1010352 | 05 | MA | MEDICAID |