Basic Information
| Provider Information | |||||||||
| NPI: | 1972703825 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOSTON MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 E CONCORD ST | ||||||||
| Address2: | 3RD FLOOR, PFS, ATTENTION: VIRGINIA MUI | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174141609 | ||||||||
| FaxNumber: | 6176387545 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BOSTON MEDICAL CTR PL | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176388000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 07/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | BARTLETT | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/VICE PRESIDENT FOR FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6176387402 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOSTON MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | V112 | MA | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 1715704 | 05 | MA | MEDICAID |