Healthcare Provider Details

I. General information

NPI: 1093756629
Provider Name (Legal Business Name): HARVARD MEDICAL FACULTY PHYS AT BETH ISRAEL DEACONESS MED CTR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE
BOSTON MA
02215
US

IV. Provider business mailing address

375 LONGWOOD AVE STE 3
BOSTON MA
02215-5395
US

V. Phone/Fax

Practice location:
  • Phone: 617-667-3101
  • Fax: 617-667-5013
Mailing address:
  • Phone: 617-632-7441
  • Fax: 617-632-7570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDRA BOER KIMBALL
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 617-632-7441