MEDICARE: COMMONWEALTH OF MASSACHUSETTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency	EXEMPT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447382817
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH OF MASSACHUSETTS

Provider Business Mailing Address
First Line	:	40 BROAD STREET
Second Line	:	4TH FLOOR
City	:	BOSTON
State	:	MA
Zip	:	02109
Country	:	US
Telephone Number	:	617-727-5608
Fax Number	:	617-624-7577

Provider Business Practice Location Address
First Line	:	38 INDUSTRIAL PARK ROAD
Second Line	:	SUITE 1
City	:	PLYMOUTH
State	:	MA
Zip	:	02360
Country	:	US
Telephone Number	:	508-732-5700
Fax Number	:	508-747-3616

Authorized Official
Title or Position	:	DEPUTY COMMISSIONER FOR ADMINISTRAT
Name	:	DYLAN LATTIMORE
Credential	:
Telephone Number	:	857-408-0675

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	03/19/2026

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Directions to “COMMONWEALTH OF MASSACHUSETTS ” Practice Location

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