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NPI Code Detail

MEDICARE: FENWAY COMMUNITY HEALTH CENTER, INC

MEDICARE: FENWAY COMMUNITY HEALTH CENTER, INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)4519MA
2261QF0400XFederally Qualified Health Center (FQHC)4519MA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1003804725
Entity Type Code : Organization
Provider Name (Legal Business Name) : FENWAY COMMUNITY HEALTH CENTER, INC
Provider Business Mailing Address
First Line : 1340 BOYLSTON ST
Second Line :
City : BOSTON
State : MA
Zip : 02215-4302
Country : US
Telephone Number : 617-927-4880
Fax Number :
Provider Business Practice Location Address
First Line : 1340 BOYLSTON ST
Second Line :
City : BOSTON
State : MA
Zip : 02215-4302
Country : US
Telephone Number : 617-927-4880
Fax Number :
Authorized Official
Title or Position : VP FINANCE & ADMINISTRATION
Name : JEFF LIEBERMAN
Credential :
Telephone Number : 617-927-6173
Provider Enumeration Date : 10/06/2005
Last Update Date : 07/07/2011

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Directions to “FENWAY COMMUNITY HEALTH CENTER, INC ” Practice Location

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