Provider Demographics
NPI:1295814812
Name:TRUSTEES OF PHILLIPS ACADEMY
Entity Type:Organization
Organization Name:TRUSTEES OF PHILLIPS ACADEMY
Other - Org Name:ISHAM HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-749-4461
Mailing Address - Street 1:180 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-4166
Mailing Address - Country:US
Mailing Address - Phone:978-749-4455
Mailing Address - Fax:978-749-4469
Practice Address - Street 1:180 MAIN ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-4166
Practice Address - Country:US
Practice Address - Phone:978-749-4455
Practice Address - Fax:978-749-4452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAEXEMPT261QS1000X
MA2165282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2226000910OtherBCBS OF MASSACHUSETT