Basic Information
| Provider Information | |||||||||
| NPI: | 1902954449 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARVARD STREET NEIGHBORHOOD HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HARVARD STREET NEIGHBORHOOD HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 632 BLUE HILL AVENUE | ||||||||
| Address2: | |||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178225520 | ||||||||
| FaxNumber: | 6172821450 | ||||||||
| Practice Location | |||||||||
| Address1: | 632 BLUE HILL AVENUE | ||||||||
| Address2: | |||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178225520 | ||||||||
| FaxNumber: | 6172821450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MURPHY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6178253400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 16544 | MA | N | Suppliers | Pharmacy | Clinic Pharmacy | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 2229121 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 110027894B | 05 | MA | MEDICAID | 1305409 | 05 | MA | MEDICAID |