Provider Demographics
NPI:1306090527
Name:COORDINATED PRIMARY CARE
Entity type:Organization
Organization Name:COORDINATED PRIMARY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
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:978-466-4268
Mailing Address - Street 1:155 FRANKLIN ROAD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420
Mailing Address - Country:US
Mailing Address - Phone:978-342-6240
Mailing Address - Fax:978-342-6240
Practice Address - Street 1:155 FRANKLIN ROAD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420
Practice Address - Country:US
Practice Address - Phone:978-342-6240
Practice Address - Fax:978-342-6240
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COORDINATED PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-14
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM20928OtherMEDICARE GROUP NUMBER
MA110072006AMedicaid
MA9771476OtherMA HEALTH GROUP NUMBER
MA9771476OtherMA HEALTH GROUP NUMBER