Basic Information
| Provider Information | |||||||||
| NPI: | 1407320823 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH PROGRAMS, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P.O., BOX 30 | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135289311 | ||||||||
| FaxNumber: | 4136440274 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 HOSPITAL AVENUE | ||||||||
| Address2: | FLOOR 3 | ||||||||
| City: | NORTH ADAMS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4136644088 | ||||||||
| FaxNumber: | 4136636405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2019 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPILIOTES | ||||||||
| AuthorizedOfficialFirstName: | AMELIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4135289311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH PROGRAMS, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 11002813N | 05 | MA | MEDICAID |