Basic Information
| Provider Information | |||||||||
| NPI: | 1497984363 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREAT BROOK VALLEY HEALTH CENTER, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088542122 | ||||||||
| FaxNumber: | 5088538593 | ||||||||
| Practice Location | |||||||||
| Address1: | 72 UNION AVE | ||||||||
| Address2: | |||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017028216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082705700 | ||||||||
| FaxNumber: | 5083703637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2009 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | KERRIGAN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5088542122 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | 4039 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.