Provider Demographics
NPI:1467524827
Name:ST. ELIZABETH'S HEALTHCARE AT HANSCOM AIR BASE
Entity Type:Organization
Organization Name:ST. ELIZABETH'S HEALTHCARE AT HANSCOM AIR BASE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MILES
Authorized Official - Middle Name:
Authorized Official - Last Name:COVERDALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-789-3000
Mailing Address - Street 1:1609 EGLIN ST
Mailing Address - Street 2:
Mailing Address - City:HANSCOM AFB
Mailing Address - State:MA
Mailing Address - Zip Code:01731-2613
Mailing Address - Country:US
Mailing Address - Phone:617-789-2204
Mailing Address - Fax:617-562-5415
Practice Address - Street 1:1609 EGLIN ST
Practice Address - Street 2:
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731-2613
Practice Address - Country:US
Practice Address - Phone:617-789-2204
Practice Address - Fax:617-562-5415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1214225Medicaid
MA220036Medicare ID - Type Unspecified