Basic Information
| Provider Information | |||||||||
| NPI: | 1780183913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY HEALTH CENTER OF WORCESTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WORCESTER EAST MIDDLE SCHOOL-SCHOOL BASED HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 QUEEN STREET | ||||||||
| Address2: | CREDENTIALING-MEDICAL SERVICES | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607962 | ||||||||
| FaxNumber: | 5088607929 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 GRAFTON ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016043802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087967037 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2018 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JUSTINIANO-FRANZEL | ||||||||
| AuthorizedOfficialFirstName: | ALYDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MGR. PROVIDER RELATIONS & CRED. | ||||||||
| AuthorizedOfficialTelephone: | 5088607962 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY HEALTH CENTER OF WORCESTER, INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 4669 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 110020639B | 05 | MA | MEDICAID |