1992745236 NPI number — HARVARD MEDICAL FACULTY PHYS AT BETH ISRAEL DEACONESS MED CTR, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992745236 NPI number — HARVARD MEDICAL FACULTY PHYS AT BETH ISRAEL DEACONESS MED CTR, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HARVARD MEDICAL FACULTY PHYS AT BETH ISRAEL DEACONESS MED CTR, 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:
NEUROLOGY - HMFP AT BIDMC
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:
1992745236
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
375 LONGWOOD AVE STE 3B
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:
02215-5395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-632-7444
Provider Business Mailing Address Fax Number:
617-632-7570

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 BROOKLINE 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:
02215-5400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-632-7441
Provider Business Practice Location Address Fax Number:
617-667-2987
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIMBALL
Authorized Official First Name:
ALEXANDRA
Authorized Official Middle Name:
BOER
Authorized Official Title or Position:
CEO AND PRESIDENT
Authorized Official Telephone Number:
617-632-7444

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9782931 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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