Basic Information
| Provider Information | |||||||||
| NPI: | 1225078801 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARVARDMEDICALFACULTYPHYSICIANS AT BETHISRAELDEACONESSMEDICALCENTER IN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GI MEDICINE - HMFP AT BIDMC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 400 BLUE HILL DRIVE | ||||||||
| Address2: | SUITE 2B | ||||||||
| City: | WESTWOOD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020902161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177541000 | ||||||||
| FaxNumber: | 6177541040 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176327441 | ||||||||
| FaxNumber: | 6176672767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 09/26/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSENBERG | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6176327441 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 9753389 | 05 | MA | MEDICAID |