Basic Information
| Provider Information | |||||||||
| NPI: | 1023049236 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE GENERAL HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 399 REVOLUTION DR | ||||||||
| Address2: | ASSEMBLY ROW 5 EAST 29-09 | ||||||||
| City: | SOMERVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021451446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8572827317 | ||||||||
| FaxNumber: | 6177266989 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 FRUIT ST | ||||||||
| Address2: | BULFINCH 360 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177262000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOEMER | ||||||||
| AuthorizedOfficialFirstName: | SALLY | ||||||||
| AuthorizedOfficialMiddleName: | MASON | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP | ||||||||
| AuthorizedOfficialTelephone: | 6177244537 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1001205 | 05 | MA | MEDICAID | 2222007130 | 01 | MA | BCBS SDC | OTHER | 900043 | 01 | MA | HARVARD PILGRIM HEALTH CA | OTHER | 0006777 | 01 | MA | NHP CHARLESTOWN HEALTHCEN | OTHER | 1202154 | 05 | MA | MEDICAID | 2222007110 | 01 | MA | BCBS OP | OTHER | 1202685 | 05 | MA | MEDICAID | 1213997 | 05 | MA | MEDICAID | 0007123 | 01 | MA | NHP OP | OTHER | 1202189 | 05 | MA | MEDICAID | 1202197 | 05 | MA | MEDICAID | 2222007101 | 01 | MA | BCBS IP | OTHER | 900166 | 01 | MA | TAHP OP | OTHER | 2222007116 | 01 | MA | BCBS HEALTHCENTERS | OTHER | 900017 | 01 | MA | TAHP IP | OTHER | 0007056 | 01 | MA | NHP IP | OTHER |