Provider Demographics
NPI:1588719488
Name:DIMOCK COMMUNITY HEALTH CENTER, INC
Entity type:Organization
Organization Name:DIMOCK COMMUNITY HEALTH CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/SVP
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GERONDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-442-8800
Mailing Address - Street 1:55 DIMOCK ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1029
Mailing Address - Country:US
Mailing Address - Phone:617-442-8800
Mailing Address - Fax:617-442-4088
Practice Address - Street 1:45 DIMOCK ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1208
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:617-442-4088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301144Medicaid
MA221862OtherMEDICARE UGS
MA221862OtherMEDICARE UGS
MA1301144Medicaid
MAM21066Medicare PIN