Provider Demographics
NPI:1518092485
Name:COORDINATED PRIMARY CARE DBA HEALTHALLIANCE PULMONARY
Entity Type:Organization
Organization Name:COORDINATED PRIMARY CARE DBA HEALTHALLIANCE PULMONARY
Other - Org Name:HEALTHALLIANCE PULMONARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
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:978-466-4268
Mailing Address - Street 1:50 MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 113
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453
Mailing Address - Country:US
Mailing Address - Phone:978-466-2692
Mailing Address - Fax:978-466-4754
Practice Address - Street 1:50 MEMORIAL DRIVE
Practice Address - Street 2:SUITE 113
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453
Practice Address - Country:US
Practice Address - Phone:978-466-2692
Practice Address - Fax:978-466-4754
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COORDINATED PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-22
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207RA0201X, 207RC0000X, 207RC0200X, 207RP1001X
MA216511207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & ImmunologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9771476Medicaid
MA9771476Medicaid