Healthcare Provider Details

I. General information

NPI: 1558791475
Provider Name (Legal Business Name): BOSTON ADVANCED MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 WINTER ST FL 2
WALTHAM MA
02451-8740
US

IV. Provider business mailing address

281 WINTER ST FL 2
WALTHAM MA
02451-8740
US

V. Phone/Fax

Practice location:
  • Phone: 781-895-7900
  • Fax: 781-290-0893
Mailing address:
  • Phone: 781-895-7900
  • Fax: 781-290-0893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ERIN KOTWICKI
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 781-895-7903