Healthcare Provider Details

I. General information

NPI: 1982995197
Provider Name (Legal Business Name): FENWAY COMMUNITY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 BERKELEY ST
BOSTON MA
02116-5100
US

IV. Provider business mailing address

1340 BOYLSTON ST
BOSTON MA
02215-4302
US

V. Phone/Fax

Practice location:
  • Phone: 617-247-7555
  • Fax:
Mailing address:
  • Phone: 617-927-6073
  • Fax: 617-927-5410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number4519
License Number StateMA

VIII. Authorized Official

Name: MR. JEFFREY M LIEBERMAN
Title or Position: VP FINANCE & ADMINISTRATION
Credential:
Phone: 617-927-6173