Healthcare Provider Details

I. General information

NPI: 1174701189
Provider Name (Legal Business Name): TRUSTEES OF BOSTON UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 CUMMINGTON ST ROOM 724
BOSTON MA
02215-2425
US

IV. Provider business mailing address

5 CUMMINGTON ST
BOSTON MA
02215-2406
US

V. Phone/Fax

Practice location:
  • Phone: 617-353-5310
  • Fax: 617-358-0338
Mailing address:
  • Phone: 617-353-5310
  • Fax: 617-358-0338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number2702
License Number StateMA

VIII. Authorized Official

Name: DR. DEAN R. TOLAN
Title or Position: DIRECTOR
Credential: PH.D.
Phone: 617-353-5310