Basic Information
Provider Information | |||||||||
NPI: | 1134306368 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHARLES RIVER COMMUNITY HEALTH, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JOSEPH M. SMITH COMMUNITY HEALTH CENTER, INC | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 495 WESTERN AVE | ||||||||
Address2: |   | ||||||||
City: | BRIGHTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021351007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177830500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 30 ATHOL ST | ||||||||
Address2: |   | ||||||||
City: | ALLSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021341124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177830500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2008 | ||||||||
LastUpdateDate: | 03/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROWNE | ||||||||
AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6172081511 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CHARLES RIVER COMMUNITY HEALTH, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | M12043 | 01 | MA | MEDICARE B | OTHER |