Healthcare Provider Details

I. General information

NPI: 1497740773
Provider Name (Legal Business Name): EASTERN ORTHODOX MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/03/2021
Certification Date: 07/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BARBER AVE
WORCESTER MA
01606-2476
US

IV. Provider business mailing address

300 BARBER AVE
WORCESTER MA
01606-2476
US

V. Phone/Fax

Practice location:
  • Phone: 508-852-1000
  • Fax: 508-854-1622
Mailing address:
  • Phone: 508-852-1000
  • Fax: 508-854-1622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0970
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2222564801
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBLUE CROSS
# 2
Identifier7100305
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerEVERCARE
# 3
Identifier0921858
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 4
Identifier802933
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerTUFTS
# 5
Identifier70012222564801
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMEDEX
# 6
Identifier904691
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerPILGRIM

VIII. Authorized Official

Name: IOANNIS MIRONIDIS
Title or Position: IT DIRECTOR
Credential:
Phone: 508-852-1000