Provider Demographics
NPI:1497984363
Name:EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC
Other - Org Name:GREAT BROOK VALLEY HEALTH CENTER, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KERRIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-854-2122
Mailing Address - Street 1:115 NE CUTOFF STE 200
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-1224
Mailing Address - Country:US
Mailing Address - Phone:508-854-2122
Mailing Address - Fax:508-853-8593
Practice Address - Street 1:72 UNION AVE
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8216
Practice Address - Country:US
Practice Address - Phone:508-270-5700
Practice Address - Fax:508-370-3637
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-13
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QF0400X
MA4039261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
221912Medicare PIN