Provider Demographics
NPI:1700152758
Name:EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KERRIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-854-2122
Mailing Address - Street 1:650 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2060
Mailing Address - Country:US
Mailing Address - Phone:508-854-2122
Mailing Address - Fax:508-853-8593
Practice Address - Street 1:585 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1906
Practice Address - Country:US
Practice Address - Phone:508-852-1805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-23
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4039261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110022061JMedicaid
221914Medicare PIN