Basic Information
| Provider Information | |||||||||
| NPI: | 1902168339 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNT AUBURN HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MAHDME DIVISION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 MOUNT AUBURN STREET | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021385502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174923500 | ||||||||
| FaxNumber: | 6174995584 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 MOUNT AUBURN STREET | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021385502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174923500 | ||||||||
| FaxNumber: | 6174995584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2012 | ||||||||
| LastUpdateDate: | 07/15/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 6174995530 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNT AUBURN HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 2898 | MA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 2222000210 | 01 | MA | OUTPATIENT BLUE CROSS | OTHER | 996324 | 01 | MA | NETWORK HEALTH | OTHER | 1201298 | 05 | MA | MEDICAID | 2222000201 | 01 | MA | INPATIENT BLUE CROSS | OTHER | 2222000205 | 01 | MA | PSYCHIATRY BLUE CROSS | OTHER | 2222000230 | 01 | MA | SURG. DAY CARE BLUE CROSS | OTHER | 900037 | 01 | MA | INPATIENT TUFTS MEDICARE PREFERRED | OTHER | 900749 | 01 | MA | OUTPATIENT TUFTS MEDICARE PREFERRED | OTHER | 0007057 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | 50-40078 | 01 | MA | UNITED HEALTH CARE | OTHER | 900023 | 01 | MA | HARVARD PILGRIM HEALTH CARE | OTHER | 0012149 | 01 | MA | AETNA | OTHER | 1099876 | 05 | MA | MEDICAID |