Provider Demographics
NPI:1376676130
Name:TOWN OF SOUTHBOROUGH
Entity Type:Organization
Organization Name:TOWN OF SOUTHBOROUGH
Other - Org Name:SOUTHBOROUGH BOARD OF HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BALLANTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-485-0710
Mailing Address - Street 1:17 COMMON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1663
Mailing Address - Country:US
Mailing Address - Phone:508-481-3013
Mailing Address - Fax:508-480-0161
Practice Address - Street 1:17 COMMON ST
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1663
Practice Address - Country:US
Practice Address - Phone:508-481-3013
Practice Address - Fax:508-480-0161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY11138Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION #
MAW67844Medicare UPIN