Provider Demographics
NPI:1457437378
Name:THE COMMONWEALTH OF MASSACHUSETTS
Entity Type:Organization
Organization Name:THE COMMONWEALTH OF MASSACHUSETTS
Other - Org Name:LEMUEL SHATTUCK HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-971-3234
Mailing Address - Street 1:170 MORTON ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3735
Mailing Address - Country:US
Mailing Address - Phone:617-522-8110
Mailing Address - Fax:
Practice Address - Street 1:170 MORTON ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3735
Practice Address - Country:US
Practice Address - Phone:617-522-8110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes281P00000XHospitalsChronic Disease Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA222320Medicare ID - Type UnspecifiedMEDICARE DIALYSIS
MA222320Medicare Oscar/Certification