Provider Demographics
NPI:1235174418
Name:BOSTON'S COMMUNITY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BOSTON'S COMMUNITY MEDICAL GROUP, INC.
Other - Org Name:CCA PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACTING MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BILJANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMIKIC
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:617-433-9601
Mailing Address - Street 1:30 NORTHAMPTON STREET
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:617-433-9601
Mailing Address - Fax:617-445-6538
Practice Address - Street 1:30 NORTHAMPTON STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-433-9601
Practice Address - Fax:617-445-6413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261QP2300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110071110AMedicaid
MAM18912OtherBCBS GROUP NUMBER
MA9757457Medicaid
MA110071110AMedicaid