Basic Information
| Provider Information | |||||||||
| NPI: | 1013935550 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIGHAM AND WOMENS PHYSICIANS ORGANIZATION INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DBA DEPT OF EMERGENCY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 CYPRESS ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024456002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175821200 | ||||||||
| FaxNumber: | 6177132283 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021156110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177325500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 04/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSTON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6177132263 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207PS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine | 207PT0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9705384 | 05 | MA | MEDICAID | M18071 | 01 | MA | BCBS EMERGENCY MED GRP # | OTHER |