Healthcare Provider Details

I. General information

NPI: 1891864039
Provider Name (Legal Business Name): UMASS MEMORIAL MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

V. Phone/Fax

Practice location:
  • Phone: 508-421-1900
  • Fax:
Mailing address:
  • Phone: 508-421-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberDS89788
License Number StateMA

VII. Legacy identifiers

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

# 1
Identifier2241646
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerNCPDP NUMBER
# 2
Identifier0407798
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: THERESE DAY
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 774-443-2848