Provider Demographics
NPI:1376502112
Name:CHILDREN'S HOSPITAL PATHOLOGY FOUNDATION, INC.
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL PATHOLOGY FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BACI
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:617-355-4589
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY - BADER 138
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-4589
Mailing Address - Fax:617-730-0674
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY - BADER 138
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-4589
Practice Address - Fax:617-730-0674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9762396Medicaid
MAM15150Medicare ID - Type Unspecified