Provider Demographics
NPI:1104880673
Name:COORDINATED PRIMARY CARE
Entity type:Organization
Organization Name:COORDINATED PRIMARY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CPC
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FABELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-466-4243
Mailing Address - Street 1:50 MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453
Mailing Address - Country:US
Mailing Address - Phone:978-466-2411
Mailing Address - Fax:978-537-9211
Practice Address - Street 1:50 MEMORIAL DRIVE
Practice Address - Street 2:SUITE 211
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453
Practice Address - Country:US
Practice Address - Phone:978-466-2411
Practice Address - Fax:978-537-9211
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COORDINATED PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-13
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9771476Medicaid
MAM20928Medicare PIN