Healthcare Provider Details

I. General information

NPI: 1194346692
Provider Name (Legal Business Name): BOSTON ALLERGY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 UNION ST
NEWTON MA
02459-2223
US

IV. Provider business mailing address

156 PROSPECT HILL RD
HARVARD MA
01451-1302
US

V. Phone/Fax

Practice location:
  • Phone: 617-965-0000
  • Fax:
Mailing address:
  • Phone: 617-965-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: ILONA DUBUSKE
Title or Position: OWNER
Credential: DO
Phone: 617-965-0000