Healthcare Provider Details

I. General information

NPI: 1396808309
Provider Name (Legal Business Name): CODMAN SQUARE HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 WASHINGTON ST
DORCHESTER CENTER MA
02124-3510
US

IV. Provider business mailing address

637 WASHINGTON ST
DORCHESTER MA
02124-3510
US

V. Phone/Fax

Practice location:
  • Phone: 617-825-9660
  • Fax: 617-288-7898
Mailing address:
  • Phone: 617-825-9660
  • Fax: 617-288-7898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. GUY FISH
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: CEO
Phone: 617-825-9660