Provider Demographics
NPI:1780780486
Name:UPHAM'S CORNER HEALTH COMMITTEE, INC.
Entity type:Organization
Organization Name:UPHAM'S CORNER HEALTH COMMITTEE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAGDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-740-8131
Mailing Address - Street 1:500 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2322
Mailing Address - Country:US
Mailing Address - Phone:617-287-8000
Mailing Address - Fax:617-282-8625
Practice Address - Street 1:500 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-2322
Practice Address - Country:US
Practice Address - Phone:617-287-8000
Practice Address - Fax:617-282-8625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X, 261QF0050X, 261QM0801X, 261QM2500X, 261QP1100X, 261QP2300X, 261QU0200X, 291U00000X, 292200000X, 261QC1500X
MA490261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No291U00000XLaboratoriesClinical Medical Laboratory
No292200000XLaboratoriesDental Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301977Medicaid
221828Medicare ID - Type Unspecified