Provider Demographics
NPI:1073744611
Name:FENWAY COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:FENWAY COMMUNITY HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-927-6479
Mailing Address - Street 1:1340 BOYLSTON ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-4302
Mailing Address - Country:US
Mailing Address - Phone:617-927-6479
Mailing Address - Fax:617-927-6150
Practice Address - Street 1:1340 BOYLSTON ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-4302
Practice Address - Country:US
Practice Address - Phone:617-927-6479
Practice Address - Fax:617-927-6150
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FENWAY HEALTH OPTOMETRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-30
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110020739BMedicaid
MA110020739BMedicaid
MA221867Medicare Oscar/Certification