Basic Information
| Provider Information | |||||||||
| NPI: | 1770574527 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARITAS ST. ELIZABETH'S MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | CARITAS ST. ELIZABETH'S MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | CARITAS ST ELIZABETHS MEDICAL CTR | ||||||||
| Address2: | P.O. BOX 3777 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022410001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175625460 | ||||||||
| FaxNumber: | 6175625480 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 WARREN ST | ||||||||
| Address2: | ST. ELIZABETHS HEALTHCARE | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175625460 | ||||||||
| FaxNumber: | 6175625480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2005 | ||||||||
| LastUpdateDate: | 09/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | CHICOINE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6177893000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1214225 | 05 | MA | MEDICAID |