Basic Information
| Provider Information | |||||||||
| NPI: | 1144864281 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH PROGRAMS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30 | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012300030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135288580 | ||||||||
| FaxNumber: | 4136440274 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 STOCKBRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012301295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135288580 | ||||||||
| FaxNumber: | 4136440274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2019 | ||||||||
| LastUpdateDate: | 11/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | ODELL | ||||||||
| AuthorizedOfficialFirstName: | AYRSLEA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4135289311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH PROGRAMS, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 133N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 110028131D | 05 | MA | MEDICAID |