Basic Information
| Provider Information | |||||||||
| NPI: | 1952327066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARVARD MEDICAL FACULTY PHYS AT BETH ISRAEL DEACONESS MED CTR, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OPHTHALMOGIC/SURGERY - HMFP@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: | 6176327444 | ||||||||
| FaxNumber: | 6176327570 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 BROOKLINE AVE | ||||||||
| Address2: | MASCO 3 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176675088 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | KIMBALL | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDRA | ||||||||
| AuthorizedOfficialMiddleName: | BOER | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6176327444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 9753419 | 05 | MA | MEDICAID |