Healthcare Provider Details

I. General information

NPI: 1518092485
Provider Name (Legal Business Name): COORDINATED PRIMARY CARE DBA HEALTHALLIANCE PULMONARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 01/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MEMORIAL DRIVE SUITE 113
LEOMINSTER MA
01453
US

IV. Provider business mailing address

50 MEMORIAL DRIVE SUITE 113
LEOMINSTER MA
01453
US

V. Phone/Fax

Practice location:
  • Phone: 978-466-2692
  • Fax: 978-466-4754
Mailing address:
  • Phone: 978-466-2692
  • Fax: 978-466-4754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number216511
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: PHYLLIS FABELLO
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 978-466-4268