Healthcare Provider Details

I. General information

NPI: 1083647648
Provider Name (Legal Business Name): BRIGHAM AND WOMENS PHYSICIANS ORGANIZATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 LONGWOOD AVE
BOSTON MA
02115-5804
US

IV. Provider business mailing address

111 CYPRESS ST
BROOKLINE MA
02445-6002
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-4918
  • Fax:
Mailing address:
  • Phone: 617-582-1200
  • Fax: 617-713-2283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM C JOHNSTON
Title or Position: CFO
Credential:
Phone: 617-713-2263