Basic Information
| Provider Information | |||||||||
| NPI: | 1770741530 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS HOSPITAL BOSTON | ||||||||
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| OtherOrganizationName: | BOSTON MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 CHAPEL ST | ||||||||
| Address2: | B501 | ||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024467458 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 LONGWOOD AVENUE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173556000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 05/29/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARCIA JACQUES | ||||||||
| AuthorizedOfficialFirstName: | JESUS | ||||||||
| AuthorizedOfficialMiddleName: | ROGELIO | ||||||||
| AuthorizedOfficialTitleorPosition: | RESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6176407670 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | 232667 | MA | Y | Hospitals | General Acute Care Hospital | Children |
ID Information
| ID | Type | State | Issuer | Description | 232667 | 01 | MA | MA BOARD OF REGISTRATION IN MEDICINE | OTHER |