Basic Information
Provider Information | |||||||||
NPI: | 1124376413 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY HEALTH CENTER OF CAPE COD INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMMUNITY HEALTH CENTER OF CAPE COD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 107 COMMERCIAL ST | ||||||||
Address2: |   | ||||||||
City: | MASHPEE | ||||||||
State: | MA | ||||||||
PostalCode: | 026496507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5084770004 | ||||||||
FaxNumber: | 5084770968 | ||||||||
Practice Location | |||||||||
Address1: | 107 COMMERCIAL ST | ||||||||
Address2: |   | ||||||||
City: | MASHPEE | ||||||||
State: | MA | ||||||||
PostalCode: | 026496507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5084770004 | ||||||||
FaxNumber: | 5084770968 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2012 | ||||||||
LastUpdateDate: | 02/20/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARDNER | ||||||||
AuthorizedOfficialFirstName: | KAREN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5085396000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | BS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0002X | MA0061072 | MA | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 110027778D | 05 | MA |   | MEDICAID | 2136341 | 01 |   | PK | OTHER |