Provider Demographics
NPI:1801099346
Name:CODMAN SQUARE HEALTH CENTER
Entity type:Organization
Organization Name:CODMAN SQUARE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAIQI
Authorized Official - Middle Name:
Authorized Official - Last Name:TAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-825-9660
Mailing Address - Street 1:637 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:637 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-3510
Practice Address - Country:US
Practice Address - Phone:617-825-9660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1211757Medicaid
MAM20951Medicare ID - Type Unspecified