Provider Demographics
NPI:1588740153
Name:ROSCOMMON HEALTHCARE WEST ROXBURY INC.
Entity type:Organization
Organization Name:ROSCOMMON HEALTHCARE WEST ROXBURY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:617-325-1688
Mailing Address - Street 1:5060 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4738
Mailing Address - Country:US
Mailing Address - Phone:617-323-5440
Mailing Address - Fax:617-469-5543
Practice Address - Street 1:5060 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4738
Practice Address - Country:US
Practice Address - Phone:617-323-5440
Practice Address - Fax:617-469-5543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0927155Medicaid
MA0927155Medicaid