Provider Demographics
NPI:1578714390
Name:COORDINATED PRIMARY CARE DBA HEALTHALLIANCE UROLOGY
Entity Type:Organization
Organization Name:COORDINATED PRIMARY CARE DBA HEALTHALLIANCE UROLOGY
Other - Org Name:
Other - Org Type:
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:978-466-4243
Mailing Address - Street 1:50 MEMORIAL DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-2238
Mailing Address - Country:US
Mailing Address - Phone:978-466-2121
Mailing Address - Fax:
Practice Address - Street 1:50 MEMORIAL DR
Practice Address - Street 2:SUITE 207
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-2238
Practice Address - Country:US
Practice Address - Phone:978-466-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COORDINATED PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM20928OtherMEDICARE GROUP NUMBER
MA9771476Medicaid