1376532853 NPI number — BOSTON UNIVERSITY DERMATOLOGY, INC.

Table of content: (NPI 1376532853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376532853 NPI number — BOSTON UNIVERSITY DERMATOLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOSTON UNIVERSITY DERMATOLOGY, INC.
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:
FACULTY PRACTICE FOUNDATION INC BOSTON UNIVERSITY DERMATOLOGY INC
Provider Other Organization Name Type Code:
4
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:
1376532853
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
960 MASSACHUSETTS AVE
Provider Second Line Business Mailing Address:
FL 2
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02118-2690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 ALBANY ST, SUITE 8B
Provider Second Line Business Practice Location Address:
SHAPIRO BLDG
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-638-7420
Provider Business Practice Location Address Fax Number:
617-638-7289
Provider Enumeration Date:
10/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ALANI
Authorized Official First Name:
RHODA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
617-638-7249

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NP0225X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3115042 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110072443A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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