Provider Demographics
NPI:1326179532
Name:FACULTY PRACTICE FOUNDATION , EVANS MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:FACULTY PRACTICE FOUNDATION , EVANS MEDICAL FOUNDATION
Other - Org Name:THE ENDOSCOPY CENTER OF BROOKLINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLOONAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-638-7231
Mailing Address - Street 1:930 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1274
Mailing Address - Country:US
Mailing Address - Phone:617-414-6600
Mailing Address - Fax:617-414-6601
Practice Address - Street 1:930 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1274
Practice Address - Country:US
Practice Address - Phone:617-414-6600
Practice Address - Fax:617-414-6601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVANS MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-08
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1320705OtherCIGNA
MA3700270OtherAETNA
MA5624667OtherFIRST HEALTH
MA623859OtherTUFTS HEALTH PLAN
MAM88035OtherBLUE CROSS BLUE SHIELD
MA0035384OtherNHP
MA623859OtherTUFTS HEALTH PLAN