Basic Information
| Provider Information | |||||||||
| NPI: | 1588719488 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIMOCK COMMUNITY HEALTH CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE DIMOCK CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 DIMOCK ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021191029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174428800 | ||||||||
| FaxNumber: | 6174424088 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 DIMOCK ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021191208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174428800 | ||||||||
| FaxNumber: | 6174424088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GERONDEAU | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO/SVP | ||||||||
| AuthorizedOfficialTelephone: | 6174428800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1301144 | 05 | MA | MEDICAID | 221862 | 01 | MA | MEDICARE UGS | OTHER |