Basic Information
| Provider Information | |||||||||
| NPI: | 1962792200 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH END COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021181951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174252000 | ||||||||
| FaxNumber: | 6174248725 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021181951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174252000 | ||||||||
| FaxNumber: | 6174248725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2011 | ||||||||
| LastUpdateDate: | 04/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6174252000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | SR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 4031 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 1301993 | 05 | MA | MEDICAID | 110009433B | 05 | MA | MEDICAID |