Provider Demographics
NPI:1437328648
Name:CODMAN SQUARE HEALTH CENTER
Entity Type:Organization
Organization Name:CODMAN SQUARE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:SEVERIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-825-9660
Mailing Address - Street 1:637 WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124
Mailing Address - Country:US
Mailing Address - Phone:617-825-9660
Mailing Address - Fax:617-288-7898
Practice Address - Street 1:637 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124
Practice Address - Country:US
Practice Address - Phone:617-825-9660
Practice Address - Fax:617-288-7898
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CODMAN SQUARE HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2748152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty