1326179532 NPI number — FACULTY PRACTICE FOUNDATION , EVANS MEDICAL FOUNDATION

Table of content: (NPI 1326179532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326179532 NPI number — FACULTY PRACTICE FOUNDATION , EVANS MEDICAL FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FACULTY PRACTICE FOUNDATION , EVANS MEDICAL FOUNDATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE ENDOSCOPY CENTER OF BROOKLINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326179532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
930 COMMONWEALTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02215-1274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-414-6600
Provider Business Mailing Address Fax Number:
617-414-6601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 COMMONWEALTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02215-1274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-414-6600
Provider Business Practice Location Address Fax Number:
617-414-6601
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLOONAN
Authorized Official First Name:
ANNMARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
617-638-7231

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1320705 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3700270 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 5624667 . This is a "FIRST HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 623859 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M88035 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0035384 . This is a "NHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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