Basic Information
| Provider Information | |||||||||
| NPI: | 1538774443 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARVARD MEDICAL FACULTY PHYS AT BETH ISRAEL DEACONESS MED CTR INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 LONGWOOD AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176327709 | ||||||||
| FaxNumber: | 6176327570 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | DEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020266022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814537200 | ||||||||
| FaxNumber: | 6177542350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2020 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | KIMBALL | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDRA | ||||||||
| AuthorizedOfficialMiddleName: | BOER | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6175660837 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.