Provider Demographics
NPI:1023561966
Name:BOSTON FOOD ALLERGY CENTER, STEWARD HEALTHCARE NETWORK
Entity Type:Organization
Organization Name:BOSTON FOOD ALLERGY CENTER, STEWARD HEALTHCARE NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-244-9859
Mailing Address - Street 1:1 NASSAU ST
Mailing Address - Street 2:UNIT 1906
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1542
Mailing Address - Country:US
Mailing Address - Phone:617-636-8858
Mailing Address - Fax:617-636-8826
Practice Address - Street 1:65 HARRISON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1924
Practice Address - Country:US
Practice Address - Phone:617-636-8858
Practice Address - Fax:617-636-8826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230907207K00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110109748AMedicaid
MA110085164A - INDIVMedicaid
MA230907OtherPROVIDER LICENSE
MAS100303553Medicare PIN