Provider Demographics
NPI:1316001761
Name:CARITAS ST.ELIZABETH'S MEDICAL CENTER-PSYCHIATRY
Entity Type:Organization
Organization Name:CARITAS ST.ELIZABETH'S MEDICAL CENTER-PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MILES
Authorized Official - Middle Name:
Authorized Official - Last Name:CONVERDALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-562-5460
Mailing Address - Street 1:77 WARREN STREET-PROVIDER ENROLLMENT DEPT
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135
Mailing Address - Country:US
Mailing Address - Phone:617-562-5482
Mailing Address - Fax:617-562-5415
Practice Address - Street 1:736 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2907
Practice Address - Country:US
Practice Address - Phone:617-789-5173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1001884Medicaid
MA1201719Medicaid
MA1201719Medicaid