Provider Demographics
NPI:1033462981
Name:BOSTONIVF-CRMI HOLDING, LLC
Entity Type:Organization
Organization Name:BOSTONIVF-CRMI HOLDING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-438-9600
Mailing Address - Street 1:130 SECOND AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1100
Mailing Address - Country:US
Mailing Address - Phone:781-434-6500
Mailing Address - Fax:781-890-8060
Practice Address - Street 1:2 MAIN ST
Practice Address - Street 2:STE 150
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3335
Practice Address - Country:US
Practice Address - Phone:781-438-9600
Practice Address - Fax:781-438-9601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOSTON IVF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-16
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1380826OtherAETNA
MAJ06571OtherBCBSMA
MA712663OtherTUFTS HEALTH PLAN
MA13397OtherHPHC
MA1285707356OtherFALLON
MA99155003OtherNETWORK HEALTH
MAM19275OtherBCBS INDEMNITY