Healthcare Provider Details

I. General information

NPI: 1467524827
Provider Name (Legal Business Name): ST. ELIZABETH'S HEALTHCARE AT HANSCOM AIR BASE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 EGLIN ST
HANSCOM AFB MA
01731-2613
US

IV. Provider business mailing address

1609 EGLIN ST
HANSCOM AFB MA
01731-2613
US

V. Phone/Fax

Practice location:
  • Phone: 617-789-2204
  • Fax: 617-562-5415
Mailing address:
  • Phone: 617-789-2204
  • Fax: 617-562-5415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MILES COVERDALE
Title or Position: CFO
Credential:
Phone: 617-789-3000