Provider Demographics
NPI:1053311514
Name:HOSPICE OF THE GOOD SHEPHERD, INC.
Entity Type:Organization
Organization Name:HOSPICE OF THE GOOD SHEPHERD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-969-6130
Mailing Address - Street 1:160 WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-3302
Mailing Address - Country:US
Mailing Address - Phone:617-969-6130
Mailing Address - Fax:617-928-1450
Practice Address - Street 1:160 WELLS AVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-3302
Practice Address - Country:US
Practice Address - Phone:617-969-6130
Practice Address - Fax:617-928-1450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0002X, 363L00000X
MA7205251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251G00000XAgenciesHospice Care, Community BasedGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110024344AMedicaid
MA110024344BMedicaid
S100276478Medicare PIN
MA110024344AMedicaid
MA221500Medicare Oscar/Certification