Provider Demographics
NPI:1285818088
Name:SOUTH COVE COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:SOUTH COVE COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:TIBERI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-521-6708
Mailing Address - Street 1:145 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-2826
Mailing Address - Country:US
Mailing Address - Phone:617-521-6708
Mailing Address - Fax:
Practice Address - Street 1:145 SOUTH ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-2826
Practice Address - Country:US
Practice Address - Phone:617-521-6708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH COVE COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4140261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
W10727OtherBLUE CROSS