Basic Information
| Provider Information | |||||||||
| NPI: | 1982995197 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FENWAY COMMUNITY HEALTH CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FENWAY SOUTH END | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 BOYLSTON ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022154302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179276073 | ||||||||
| FaxNumber: | 6179275410 | ||||||||
| Practice Location | |||||||||
| Address1: | 142 BERKELEY ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021165100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172477555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2011 | ||||||||
| LastUpdateDate: | 07/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | LIEBERMAN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE & ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 6179276173 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FENWAY COMMUNITY HEALTH CENTER, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 4519 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 110020739D | 05 | MA | MEDICAID |