Basic Information
| Provider Information | |||||||||
| NPI: | 1982937090 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMBRIDGE PUBLIC HEALTH COMMISSION/DBA/CAMBRIDGE HEALTH ALLIANCE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHAPO | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1493 CAMBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021391047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176651000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1493 CAMBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021391047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176651000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2009 | ||||||||
| LastUpdateDate: | 09/09/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PORELL | ||||||||
| AuthorizedOfficialFirstName: | DAVE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAPO CAO | ||||||||
| AuthorizedOfficialTelephone: | 6174996621 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | IN PROCESS | 01 | BCBS NON PCHI GROUP | OTHER |