Basic Information
| Provider Information | |||||||||
| NPI: | 1033157771 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOSTON HEALTH CARE FOR THE HOMELESS PROGRAM, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MCINNIS HEALTH GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 780 ALBANY STREET | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8576541227 | ||||||||
| FaxNumber: | 8576541404 | ||||||||
| Practice Location | |||||||||
| Address1: | 780 ALBANY STREET | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8576541000 | ||||||||
| FaxNumber: | 8576541404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEUNG | ||||||||
| AuthorizedOfficialFirstName: | AGNES | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8576541200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 4LQX | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1310828 | 05 | MA | MEDICAID |