Provider Demographics
NPI:1992745236
Name:HARVARD MEDICAL FACULTY PHYS AT BETH ISRAEL DEACONESS MED CTR, INC
Entity type:Organization
Organization Name:HARVARD MEDICAL FACULTY PHYS AT BETH ISRAEL DEACONESS MED CTR, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:BOER
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-632-7444
Mailing Address - Street 1:375 LONGWOOD AVE STE 3B
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5395
Mailing Address - Country:US
Mailing Address - Phone:617-632-7444
Mailing Address - Fax:617-632-7570
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-632-7441
Practice Address - Fax:617-667-2987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9782931Medicaid
MA9782931Medicaid