1548589047 NPI number — FENWAY COMMUNITY HEALTH CENTER, INC

Table of content: (NPI 1548589047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548589047 NPI number — FENWAY COMMUNITY HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FENWAY COMMUNITY HEALTH CENTER, 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:
SIDNEY BORUM JR. HEALTH CENTER OF FENWAY HEALTH
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:
1548589047
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1340 BOYLSTON ST
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:
02215-4302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-927-6173
Provider Business Mailing Address Fax Number:
617-927-5410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 KNEELAND ST
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02111-1901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-457-8140
Provider Business Practice Location Address Fax Number:
617-457-8141
Provider Enumeration Date:
05/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LIEBERMAN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
VP FINANACE & ADMINISTRATION
Authorized Official Telephone Number:
617-927-6173

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  4519 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0801X , with the licence number: 4519 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 110024430F , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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