Provider Demographics
NPI:1316023195
Name:UPHAM'S CORNER HEALTH COMMITTEE, INC.
Entity Type:Organization
Organization Name:UPHAM'S CORNER HEALTH COMMITTEE, INC.
Other - Org Name:UPHAM'S ELDER SERVICE PLAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAGDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-740-8131
Mailing Address - Street 1:500 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2322
Mailing Address - Country:US
Mailing Address - Phone:617-288-0970
Mailing Address - Fax:617-282-8625
Practice Address - Street 1:1140 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-3305
Practice Address - Country:US
Practice Address - Phone:617-288-0970
Practice Address - Fax:617-474-0757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1803344Medicaid
H2220Medicare ID - Type Unspecified