Healthcare Provider Details

I. General information

NPI: 1003060955
Provider Name (Legal Business Name): BETH ISRAEL DEACONESS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE
BOSTON MA
02215-5400
US

IV. Provider business mailing address

330 BROOKLINE AVE
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-677-4042
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code281PC2000X
TaxonomyChildren's Chronic Disease Hospital
License Number
License Number StateMA

VIII. Authorized Official

Name: STEPHEN DEVEAU
Title or Position: CONTROLLER & DIRECTOR, FISCAL SERVI
Credential:
Phone: 617-667-0003