Provider Demographics
NPI:1093856965
Name:THE COMMONWEALTH OF MASSACHUSETTS
Entity Type:Organization
Organization Name:THE COMMONWEALTH OF MASSACHUSETTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CULLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-624-5626
Mailing Address - Street 1:305 SOUTH STREET
Mailing Address - Street 2:MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH-IMMUNIZATION
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:617-983-6800
Mailing Address - Fax:617-983-6840
Practice Address - Street 1:305 SOUTH STREET
Practice Address - Street 2:MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH-IMMUNIZATION
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:617-983-6800
Practice Address - Fax:617-983-6840
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE COMMONWEALTH OF MASSACHUSETTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-12
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY11070Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER