Provider Demographics
NPI:1124118229
Name:CHMC OTOLARYNGOLOGIC FOUNDATION, INC
Entity type:Organization
Organization Name:CHMC OTOLARYNGOLOGIC FOUNDATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-355-6463
Mailing Address - Street 1:PO BOX 4162
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01888-4162
Mailing Address - Country:US
Mailing Address - Phone:617-355-6460
Mailing Address - Fax:617-730-0611
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:LO 367
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-6460
Practice Address - Fax:617-730-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110028764BOtherMEDICAID PID
MA9723153Medicaid
A36455Medicare UPIN
MA110028764BOtherMEDICAID PID