Healthcare Provider Details

I. General information

NPI: 1033462981
Provider Name (Legal Business Name): BOSTONIVF-CRMI HOLDING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MAIN ST STE 150
STONEHAM MA
02180-3335
US

IV. Provider business mailing address

130 SECOND AVE
WALTHAM MA
02451-1100
US

V. Phone/Fax

Practice location:
  • Phone: 781-438-9600
  • Fax: 781-438-9601
Mailing address:
  • Phone: 781-434-6500
  • Fax: 781-890-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: GAIL K HENDRICKSON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 781-438-9600