Basic Information
| Provider Information | |||||||||
| NPI: | 1669794087 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIGHAM AND WOMENS PHYSICIANS ORGANIZATION INC | ||||||||
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| OtherOrganizationName: | DEPT OF FAULKNER PATHOLOGY | ||||||||
| 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: | 02/26/2010 | ||||||||
| LastUpdateDate: | 04/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | CLIFFORD | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER, PAYER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6177132242 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0006X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 9713140 | 05 | MA | MEDICAID | M18375 | 01 | MA | BCBS OF MA | OTHER | 696752 | 01 | MA | RR MEDICARE | OTHER |