Healthcare Provider Details

I. General information

NPI: 1770741530
Provider Name (Legal Business Name): CHILDRENS HOSPITAL BOSTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVENUE
BOSTON MA
02115
US

IV. Provider business mailing address

20 CHAPEL ST B501
BROOKLINE MA
02446-7458
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number232667
License Number StateMA

VIII. Authorized Official

Name: JESUS ROGELIO GARCIA JACQUES
Title or Position: RESIDENT
Credential: M.D.
Phone: 617-640-7670