Provider Demographics
NPI:1902240047
Name:COMMONWEALTH OF MASSACHUSETTS
Entity Type:Organization
Organization Name:COMMONWEALTH OF MASSACHUSETTS
Other - Org Name:MASSACHUSETTS MARITIME ACADEMY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR, HEALTH SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:CUKOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-830-5048
Mailing Address - Street 1:101 ACADEMY DR
Mailing Address - Street 2:HEALTH SERVICES
Mailing Address - City:BUZZARDS BAY
Mailing Address - State:MA
Mailing Address - Zip Code:02532-3405
Mailing Address - Country:US
Mailing Address - Phone:508-830-5048
Mailing Address - Fax:508-830-5004
Practice Address - Street 1:101 ACADEMY DR
Practice Address - Street 2:HEALTH SERVICES
Practice Address - City:BUZZARDS BAY
Practice Address - State:MA
Practice Address - Zip Code:02532-3405
Practice Address - Country:US
Practice Address - Phone:508-830-5048
Practice Address - Fax:508-830-5004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health