=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013048347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2007
-----------------------------------------------------
Last Update Date | 11/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 TACOMA ST
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01605-3516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-854-2128
-----------------------------------------------------
Fax | 508-595-1127
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 LINCOLN ST
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01605-2060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-854-2122
-----------------------------------------------------
Fax | 508-853-8593
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | MR. STEPHEN J KERRIGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 508-854-2122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number | 495
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------