Basic Information
| Provider Information | |||||||||
| NPI: | 1750486106 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLES RIVER COMMUNITY HEALTH, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 495 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021351007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816933800 | ||||||||
| FaxNumber: | 6179878222 | ||||||||
| Practice Location | |||||||||
| Address1: | 43 FOUNDRY AVE | ||||||||
| Address2: | |||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024538313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177830500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | BROWNE | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6172051511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 4157 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 2227002110 | 01 | MA | BCBS | OTHER | 1320882 | 05 | MA | MEDICAID | W20419 | 01 | MA | BCBS - OPTOMETRY | OTHER | 903699 | 01 | MA | TUFTS HEALTH PLAN - MH | OTHER | M12043 | 01 | MA | BCBS MEDICAL/PODIATRY | OTHER | 686893 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 110024306T | 05 | MA | MEDICAID | 682536 | 01 | MA | TUFTS HEALTH PLAN - MED | OTHER |