Healthcare Provider Details

I. General information

NPI: 1003804725
Provider Name (Legal Business Name): FENWAY COMMUNITY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BOYLSTON ST
BOSTON MA
02215-4302
US

IV. Provider business mailing address

1340 BOYLSTON ST
BOSTON MA
02215-4302
US

V. Phone/Fax

Practice location:
  • Phone: 617-927-4880
  • Fax:
Mailing address:
  • Phone: 617-927-4880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number4519
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number4519
License Number StateMA

VIII. Authorized Official

Name: JEFF LIEBERMAN
Title or Position: VP FINANCE & ADMINISTRATION
Credential:
Phone: 617-927-6173