Basic Information
| Provider Information | |||||||||
| NPI: | 1790113389 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARVARD MEDICAL FACULTY PHYS AT BETH ISRAEL DEACONESS MED CTR INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORTHOPAEDIC SURGERY-HMFP AT BIDMC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 LONGWOOD AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176327441 | ||||||||
| FaxNumber: | 6176327570 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 ALLIED DR STE 104 | ||||||||
| Address2: | |||||||||
| City: | DEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020266146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176670227 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2013 | ||||||||
| LastUpdateDate: | 12/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | KIMBALL | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDRA | ||||||||
| AuthorizedOfficialMiddleName: | BOER | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6176327441 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.