Basic Information
| Provider Information | |||||||||
| NPI: | 1285691337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOSTON UNIVERSITY EYE ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 HARRISON AVE # ACC-3 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021184001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174144020 | ||||||||
| FaxNumber: | 6174144028 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 HARRISON AVE # ACC-3 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021184001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174144020 | ||||||||
| FaxNumber: | 6174144028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTIANSEN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 5088237473 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D., MPH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 9766162 | 05 | MA | MEDICAID | M15524 | 01 | MA | BCBS | OTHER |