Provider Demographics
NPI:1225228679
Name:BOSTON MEDICAL CENTER CORPORATION
Entity Type:Organization
Organization Name:BOSTON MEDICAL CENTER CORPORATION
Other - Org Name:SOUTH BOSTON COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:AKINOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNGBADERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-269-7500
Mailing Address - Street 1:409 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2245
Mailing Address - Country:US
Mailing Address - Phone:617-269-7500
Mailing Address - Fax:617-464-7581
Practice Address - Street 1:409 W BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2245
Practice Address - Country:US
Practice Address - Phone:617-269-7500
Practice Address - Fax:617-464-7581
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOSTON MEDICAL CENTER CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-31
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAV112261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
220031Medicare Oscar/Certification