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General NPI Number Information
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NPI Number | 1023561966
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Entity Type | Organization
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Legal Business Name | BOSTON FOOD ALLERGY CENTER, STEWARD HEALTHCARE NETWORK
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Dates
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Enumeration Date | 07/27/2016
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Last Update Date | 07/27/2016
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Provider Practice Location Address
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Address Line | 65 HARRISON AVE SUITE 201
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City | BOSTON
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State | MA
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Zip | 02111-1924
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Country | US
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Telephone | 617-636-8858
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Fax | 617-636-8826
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Provider Business Mailing Address
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Address Line | 1 NASSAU ST UNIT 1906
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City | BOSTON
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State | MA
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Zip | 02111-1542
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Country | US
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Telephone | 617-636-8858
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Fax | 617-636-8826
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | SHAUN WHITE
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Credential |
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Telephone | 502-244-9859
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 230907
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 230907
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License Number State | MA
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