Provider Demographics
NPI:1275612103
Name:THE COMMONWEALTH OF MASSACHUSETTS
Entity Type:Organization
Organization Name:THE COMMONWEALTH OF MASSACHUSETTS
Other - Org Name:LEMUEL SHATTUCK HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUREAU DIRECTOR, PUBLIC HEALTH HOSP
Authorized Official - Prefix:
Authorized Official - First Name:VALENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIPTAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-784-9186
Mailing Address - Street 1:170 MORTON STREET
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3735
Mailing Address - Country:US
Mailing Address - Phone:617-522-8110
Mailing Address - Fax:617-971-3850
Practice Address - Street 1:170 MORTON STREET
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3735
Practice Address - Country:US
Practice Address - Phone:617-522-8110
Practice Address - Fax:617-971-3850
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE COMMONWEALTH OF MASSACHUSETTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-02
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No281P00000XHospitalsChronic Disease Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110078189DMedicaid
MA1201018Medicaid