Provider Demographics
NPI:1396906848
Name:FITCHBURG STATE COLLEGE- HEALTH SERVICES
Entity type:Organization
Organization Name:FITCHBURG STATE COLLEGE- HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAVRE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:978-665-3216
Mailing Address - Street 1:160 PEARL ST
Mailing Address - Street 2:FITCHBURG STATE COLLEGE -HEALTH SERVICES
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-2631
Mailing Address - Country:US
Mailing Address - Phone:978-665-3216
Mailing Address - Fax:978-665-3641
Practice Address - Street 1:160 PEARL ST
Practice Address - Street 2:FITCHBURG STATE COLLEGE -HEALTH SERVICES
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-2631
Practice Address - Country:US
Practice Address - Phone:978-665-3216
Practice Address - Fax:978-665-3641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA164930261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FA NP4356Medicare PIN