| Contacts | Primary Contact | Update | Profile Change Request | Sturm, Benjamin
Director of Pharmacy & Optometry
Charles River Community Health
6178707448 | Sturm, Benjamin
Director of Pharmacy
Charles River Community Health
6178707448 | 4/9/2025 3:31 PM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2024 4:18:02 PM | 2/27/2025 3:49:40 PM | 2/27/2025 3:49 PM |
| Contacts | Authorizing Official | Update | Group Change Request | Browne, Elizabeth
CEO
Charles River Community Health
6172081511 | Mullaney, Matthew L.
Chief Executive Officer
Charles River Community Health
7814006221 | 1/21/2025 2:18 PM |
| Details | Last Recertification Date | Update | Recertification | 2/17/2023 3:36:57 PM | 1/29/2024 4:18:02 PM | 1/29/2024 4:18 PM |
| Details | Last Recertification Date | Update | Recertification | 2/8/2022 5:11:07 PM | 2/17/2023 3:36:57 PM | 2/17/2023 3:36 PM |
| Addresses | Main Address | Update | Recertification |
43 Foundry Avenue
Waltham, MA 02453-8313 |
43 Foundry Avenue
Suite 110
Waltham, MA 02453-8313 | 2/8/2022 5:11 PM |
| Details | Last Recertification Date | Update | Recertification | 2/19/2021 9:01:50 AM | 2/8/2022 5:11:07 PM | 2/8/2022 5:11 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | MA | 2/19/2021 9:01 AM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2020 10:09:44 AM | 2/19/2021 9:01:50 AM | 2/19/2021 9:01 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Browne, Elizabeth
Executive Director
Charles River Community Health
6172081511 | Browne, Elizabeth
CEO
Charles River Community Health
6172081511 | 2/5/2021 2:49 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Sturm, Benjamin
Assoc. Director of Pharmacy
Charles River Community Health
6178707448 | Sturm, Benjamin
Director of Pharmacy & Optometry
Charles River Community Health
6178707448 | 2/5/2021 12:39 PM |
| Medicaid Billing | Medicaid: Number | Update | Recertification | 110024306N | 110024306S | 1/29/2020 10:09 AM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2019 10:23:09 AM | 1/29/2020 10:09:44 AM | 1/29/2020 10:09 AM |
| Contacts | Primary Contact | Update | Change Request | Souza, James
CFO
Charles River Community Health
6178707280 | Sturm, Benjamin
Assoc. Director of Pharmacy
Charles River Community Health
6178707448 | 1/30/2019 12:37 PM |
| Details | Last Recertification Date | Update | Recertification | 2/15/2018 7:54:20 AM | 1/30/2019 10:23:09 AM | 1/30/2019 10:23 AM |
| Addresses | Main Address | Update | Recertification |
564 Main St
Waltham, MA 02452-5516 |
43 Foundry Avenue
Waltham, MA 02453-8313 | 2/15/2018 7:54 AM |
| Contacts | Primary Contact | Update | Recertification | SOUZA, JAMES
CFO
6178707280 | Souza, James
CFO
Charles River Community Health
6178707280 | 2/15/2018 7:54 AM |
| Details | Last Recertification Date | Update | Recertification | 2/7/2017 12:00:00 AM | 2/15/2018 7:54:20 AM | 2/15/2018 7:54 AM |
| Details | Entity Name | Update | Recertification | Charles River Cummunity Health at Waltham | Charles River Community Health at Waltham | 2/15/2018 7:54 AM |
| Contacts | Authorizing Official | Update | AO Change Request | BROWNE, ELIZABETH
EXECUTIVE DIRECTOR
6172081611 | Browne, Elizabeth
Executive Director
Charles River Community Health
6172081511 | 2/13/2018 2:52 PM |
| Contacts | Authorizing Official | Insert | | | BROWNE, ELIZABETH
EXECUTIVE DIRECTOR
6172081611 | 5/11/2017 5:06 PM |
| Contacts | Signed By | Insert | | | BROWNE, ELIZABETH
EXECUTIVE DIRECTOR
6172081611 | 5/11/2017 5:06 PM |
| Addresses | Main Address | Insert | | |
564 MAIN ST
Waltham, MA 02452-5516 | 2/7/2017 11:58 AM |
| Contacts | Primary Contact | Insert | | | SOUZA, JAMES
CFO
6178707280 | 2/7/2017 11:58 AM |
| Details | Last Recertification Date | Update | | 3/4/2016 12:00:00 AM | 2/7/2017 12:00:00 AM | 2/7/2017 11:58 AM |
| Details | Entity Name | Update | | JOSEPH M. SMITH COMMUNITY HEALTH CENTER, INC. | Charles River Cummunity Health at Waltham | 3/15/2016 3:10 PM |
| Details | Entity Subname | Update | | Joseph M. Smith Community Health Center at Waltham | | 3/15/2016 3:10 PM |
| Details | Last Recertification Date | Update | | 2/12/2015 12:00:00 AM | 3/4/2016 12:00:00 AM | 3/4/2016 3:08 PM |
| Details | Last Recertification Date | Update | | 3/15/2014 12:00:00 AM | 2/12/2015 12:00:00 AM | 2/12/2015 12:48 PM |
| Details | Entity Name | Update | | Joseph M Smith Community Health Center, Inc | JOSEPH M. SMITH COMMUNITY HEALTH CENTER, INC. | 3/15/2014 9:09 AM |
| Details | Entity Subname | Update | | Center at Waltham | Joseph M. Smith Community Health Center at Waltham | 3/15/2014 9:09 AM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/15/2014 12:00:00 AM | 3/15/2014 9:05 AM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/27/2013 12:48 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 7/2/2012 2:42 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 110024306N | 7/2/2012 2:42 PM |
| Medicaid Billing | Medicaid: State | Insert | | | MA | 7/2/2012 2:42 PM |
| Details | 340B ID | Update | | IS-FF-CH01189A | CH01189A | 6/19/2012 5:33 PM |
| Dates | Participating Approval Date | Update | | | 6/19/2012 12:00:00 AM | 6/19/2012 5:33 PM |
| Details | State | Update | | Pending | Active | 6/19/2012 5:33 PM |
| Dates | Start Date | Update | | | 7/1/2012 12:00:00 AM | 6/19/2012 5:33 PM |
| Details | Grant Number | Update | | | H80CS00378 | 6/11/2012 10:19 AM |
| Details | 340B ID | Update | | ONLINE_REG | IS-FF-CH01189A | 6/11/2012 10:19 AM |
| Details | Entity Subname | Update | | | Center at Waltham | 6/11/2012 10:19 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1639445034 | 4/24/2012 8:48 PM |
| Details | Last Recertification Date | Insert | | | | 4/24/2012 8:48 PM |
| Details | Grant Number | Insert | | | | 4/24/2012 8:48 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 4/24/2012 8:48 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/24/2012 8:48 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/24/2012 8:48 PM |
| Details | Medicare Provider Number | Insert | | | | 4/24/2012 8:48 PM |
| Details | Entity Name | Insert | | | Joseph M Smith Community Health Center, Inc | 4/24/2012 8:48 PM |
| Details | Program Code | Insert | | | CH | 4/24/2012 8:48 PM |
| Details | Entity Subname | Insert | | | | 4/24/2012 8:48 PM |
| Dates | Participating Approval Date | Insert | | | | 4/24/2012 8:48 PM |
| Details | State | Insert | | | Pending | 4/24/2012 8:48 PM |
| Dates | Registration Date | Insert | | | 4/24/2012 12:00:00 AM | 4/24/2012 8:48 PM |
| Dates | Signed By Date | Insert | | | 4/24/2012 12:00:00 AM | 4/24/2012 8:48 PM |
| Dates | Start Date | Insert | | | | 4/24/2012 8:48 PM |
| Terminations | Termination Comments | Insert | | | | 4/24/2012 8:48 PM |
| Terminations | Termination Date | Insert | | | | 4/24/2012 8:48 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/24/2012 8:48 PM |
| Terminations | Termination Reason | Insert | | | | 4/24/2012 8:48 PM |