Provider Demographics
NPI:1225083579
Name:BOSTON SPINE TEACHING AND RESEARCH FOUNDATION INC.
Entity Type:Organization
Organization Name:BOSTON SPINE TEACHING AND RESEARCH FOUNDATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JUDE
Authorized Official - Last Name:BANCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-219-6300
Mailing Address - Street 1:P.O. BOX 4110
Mailing Address - Street 2:DEPARTMENT 3110
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01888-4110
Mailing Address - Country:US
Mailing Address - Phone:781-619-0173
Mailing Address - Fax:781-551-5888
Practice Address - Street 1:299 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458-1612
Practice Address - Country:US
Practice Address - Phone:617-219-6300
Practice Address - Fax:617-219-6366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59668207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM19066OtherBCBS MA
MAM21737Medicare ID - Type Unspecified