1023561966 NPI number — BOSTON FOOD ALLERGY CENTER, STEWARD HEALTHCARE NETWORK

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 1023561966 NPI number — BOSTON FOOD ALLERGY CENTER, STEWARD HEALTHCARE NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOSTON FOOD ALLERGY CENTER, STEWARD HEALTHCARE NETWORK
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:
Provider Other Organization Name Type Code:
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:
1023561966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 NASSAU ST
Provider Second Line Business Mailing Address:
UNIT 1906
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02111-1542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-636-8858
Provider Business Mailing Address Fax Number:
617-636-8826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
65 HARRISON AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02111-1924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-636-8858
Provider Business Practice Location Address Fax Number:
617-636-8826
Provider Enumeration Date:
07/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
SHAUN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
502-244-9859

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  230907 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X , with the licence number: 230907 , 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: 110109748A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110085164A - INDIV , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 230907 . This is a "PROVIDER LICENSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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