Provider Demographics
NPI:1093069858
Name:PRESIDENT AND FELLOWS OF HARVARD COLLEGE
Entity Type:Organization
Organization Name:PRESIDENT AND FELLOWS OF HARVARD COLLEGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DEAN OF CLINICAL OPERATIO
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-432-4276
Mailing Address - Street 1:30 BERTSON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-3221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5819
Practice Address - Country:US
Practice Address - Phone:617-432-1434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADF10843261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental