Basic Information
Provider Information | |||||||||
NPI: | 1295806636 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | O'NEILL HEALTH CLINIC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DUFFY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 61 BRANT WAY | ||||||||
Address2: |   | ||||||||
City: | HYANNIS | ||||||||
State: | MA | ||||||||
PostalCode: | 026012162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087762656 | ||||||||
FaxNumber: | 5087904858 | ||||||||
Practice Location | |||||||||
Address1: | 105 PARK ST | ||||||||
Address2: |   | ||||||||
City: | HYANNIS | ||||||||
State: | MA | ||||||||
PostalCode: | 026015205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087711218 | ||||||||
FaxNumber: | 5087710070 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOYER | ||||||||
AuthorizedOfficialFirstName: | CLAIRE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5087719599 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 113425 | MA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 1588616742 | 01 | MA | NATIONAL PROVIDER ID | OTHER |