Healthcare Provider Details

I. General information

NPI: 1023561966
Provider Name (Legal Business Name): BOSTON FOOD ALLERGY CENTER, STEWARD HEALTHCARE NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 HARRISON AVE SUITE 201
BOSTON MA
02111-1924
US

IV. Provider business mailing address

1 NASSAU ST UNIT 1906
BOSTON MA
02111-1542
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-8858
  • Fax: 617-636-8826
Mailing address:
  • Phone: 617-636-8858
  • Fax: 617-636-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number230907
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number230907
License Number StateMA

VIII. Authorized Official

Name: SHAUN WHITE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 502-244-9859