Provider Demographics
NPI:1720112592
Name:MGH FAMILY CARE PROGRAM
Entity type:Organization
Organization Name:MGH FAMILY CARE PROGRAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEC. DIRECTOR OF SOCIAL SERVICE
Authorized Official - Prefix:DR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:617-726-2657
Mailing Address - Street 1:32 FRUIT ST
Mailing Address - Street 2:WACC LOBBY 037
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2620
Mailing Address - Country:US
Mailing Address - Phone:617-724-0759
Mailing Address - Fax:617-726-7676
Practice Address - Street 1:32 FRUIT ST
Practice Address - Street 2:WACC LOBBY 037
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2620
Practice Address - Country:US
Practice Address - Phone:617-724-0759
Practice Address - Fax:617-726-7676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1904191Medicaid