Provider Demographics
NPI:1457471286
Name:COMMONWEALTH OF MASSACHUSETTS-DMH
Entity Type:Organization
Organization Name:COMMONWEALTH OF MASSACHUSETTS-DMH
Other - Org Name:SOUTH WEST SUBURBAN SITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SITE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-401-9702
Mailing Address - Street 1:5 RANDOLPH ST
Mailing Address - Street 2:DONOVAN BUILDING, 2ND FLOOR
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-2352
Mailing Address - Country:US
Mailing Address - Phone:781-401-9700
Mailing Address - Fax:
Practice Address - Street 1:5 RANDOLPH ST
Practice Address - Street 2:DONOVAN BUILDING, 2ND FLOOR
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2352
Practice Address - Country:US
Practice Address - Phone:781-401-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1802356Medicaid