Healthcare Provider Details

I. General information

NPI: 1871523753
Provider Name (Legal Business Name): BOSTON PEDIATRIC NEUROSURGICAL FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE DEPARTMENT OF NEUROSURGERY, CHILDREN'S HOSPITAL BOSTON
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE., HUNNEWELL 2 DEPARTMENT OF NEUROSURGERY, CHILDREN'S HOSPITAL BOSTON
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6446
  • Fax: 617-730-0906
Mailing address:
  • Phone: 617-355-6446
  • Fax: 617-730-0906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN M HICKEY
Title or Position: PROVIDER ENROLLMENT MANAGER
Credential:
Phone: 617-355-4956