MEDICARE: COMMONWEALTH OF MASSACHUSETTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS1000X	Student Health Clinic/Center

General Provider Information

NPI Number	:	1902240047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH OF MASSACHUSETTS

Provider Business Mailing Address
First Line	:	101 ACADEMY DR
Second Line	:	HEALTH SERVICES
City	:	BUZZARDS BAY
State	:	MA
Zip	:	02532-3405
Country	:	US
Telephone Number	:	508-830-5048
Fax Number	:	508-830-5004

Provider Business Practice Location Address
First Line	:	101 ACADEMY DR
Second Line	:	HEALTH SERVICES
City	:	BUZZARDS BAY
State	:	MA
Zip	:	02532-3405
Country	:	US
Telephone Number	:	508-830-5048
Fax Number	:	508-830-5004

Authorized Official
Title or Position	:	DIRECTOR, HEALTH SERVICES
Name	:	DR. JEFFREY CUKOR
Credential	:	MD
Telephone Number	:	508-830-5048

Provider Enumeration Date	:	04/19/2013
Last Update Date	:	04/19/2013

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