Basic Information
| Provider Information | |||||||||
| NPI: | 1548663875 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROCKTON NEIGHBORHOOD HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023013907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085596699 | ||||||||
| FaxNumber: | 5085595073 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085596699 | ||||||||
| FaxNumber: | 5085595073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2014 | ||||||||
| LastUpdateDate: | 05/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | BENSON | ||||||||
| AuthorizedOfficialFirstName: | MELVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5085596699 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 4896 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 110028118/A | 01 | MA | MASSHEALTH | OTHER | 0006827 | 01 | MA | NHP | OTHER | BLUECROSS BLUESHIELD | 01 | MA | M18107 | OTHER | M20905 | 01 | MA | MEDICARE PART B | OTHER | 221830 | 01 | MA | MEDICARE PART A | OTHER | 606260 | 01 | MA | 606260 | OTHER | 000000021197 | 05 | MA | MEDICAID | 0192330 | 01 | MA | UNITED CARE | OTHER |