Basic Information
| Provider Information | |||||||||
| NPI: | 1457397986 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITTIER STREET HEALTH CENTER COMMITTEE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WHITTIER STREET HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 TREMONT ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY CROSSING | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174271000 | ||||||||
| FaxNumber: | 6178582674 | ||||||||
| Practice Location | |||||||||
| Address1: | 1290 TREMONT ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY CROSSING | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174271000 | ||||||||
| FaxNumber: | 6178582674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO / VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6179893230 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 4144 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1399578 | 05 | MA | MEDICAID |