Basic Information
| Provider Information | |||||||||
| NPI: | 1689318503 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FENWAY COMMUNITY HEALTH CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847492 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022847492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179276050 | ||||||||
| FaxNumber: | 6179275410 | ||||||||
| Practice Location | |||||||||
| Address1: | 359 GREEN ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021393334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179276050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2022 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | DANIEL | ||||||||
| AuthorizedOfficialFirstName: | MOIRE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BILLING AND COLLECTIONS | ||||||||
| AuthorizedOfficialTelephone: | 6179276279 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FENWAY COMMUNITY HEALTH CENTER, INC | ||||||||
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| NPICertificationDate: | 04/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1303546 | 05 | MA | MEDICAID |