Provider Demographics
NPI:1922599117
Name:CODMAN SQUARE HEALTH CENTER, INC
Entity Type:Organization
Organization Name:CODMAN SQUARE HEALTH CENTER, INC
Other - Org Name:CODMAN SQUARE HEALTH CENTER URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:TARSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:COO
Authorized Official - Phone:617-822-8744
Mailing Address - Street 1:637 WASHINGTON STREET
Mailing Address - Street 2:URGENT CARE DEPARTMENT
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3510
Mailing Address - Country:US
Mailing Address - Phone:617-822-8725
Mailing Address - Fax:617-822-8244
Practice Address - Street 1:637 WASHINGTON STREET
Practice Address - Street 2:URGENT CARE DEPARTMENT
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-3510
Practice Address - Country:US
Practice Address - Phone:617-822-8725
Practice Address - Fax:617-822-8244
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CODMAN SQUARE HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-23
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110022129FMedicaid