Provider Demographics
NPI:1477535813
Name:COORDINATED PRIMARY CARE
Entity Type:Organization
Organization Name:COORDINATED PRIMARY CARE
Other - Org Name:ONCOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR COORDINATOR PRIMARY CARE
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FABELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-466-4243
Mailing Address - Street 1:60 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453
Mailing Address - Country:US
Mailing Address - Phone:978-466-4243
Mailing Address - Fax:978-466-2238
Practice Address - Street 1:275 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420
Practice Address - Country:US
Practice Address - Phone:978-343-5048
Practice Address - Fax:978-343-5549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0003X
MAM20928363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM20928OtherMEDICARE GROUP
MA977147CMedicaid
MAM20928OtherMEDICARE GROUP