Basic Information
Provider Information | |||||||||
NPI: | 1548589047 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FENWAY COMMUNITY HEALTH CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SIDNEY BORUM JR. HEALTH CENTER OF FENWAY HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1340 BOYLSTON ST | ||||||||
Address2: |   | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 022154302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6179276173 | ||||||||
FaxNumber: | 6179275410 | ||||||||
Practice Location | |||||||||
Address1: | 75 KNEELAND ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021111901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6174578140 | ||||||||
FaxNumber: | 6174578141 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2010 | ||||||||
LastUpdateDate: | 09/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LIEBERMAN | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANACE & ADMINISTRATION | ||||||||
AuthorizedOfficialTelephone: | 6179276173 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FENWAY COMMUNITY HEALTH CENTER INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 4519 | MA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QC1500X | 4519 | MA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
ID | Type | State | Issuer | Description | 110024430F | 05 | MA |   | MEDICAID |