Healthcare Provider Details

I. General information

NPI: 1134166390
Provider Name (Legal Business Name): BOSTON UNIVERSITY FAMILY MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOSTON MEDICAL CTR PL
BOSTON MA
02118-2908
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE FL 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-2080
  • Fax: 617-414-2090
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHEN A. WILSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 617-414-2080