Provider Demographics
NPI:1376532853
Name:BOSTON UNIVERSITY DERMATOLOGY, INC.
Entity Type:Organization
Organization Name:BOSTON UNIVERSITY DERMATOLOGY, INC.
Other - Org Name:FACULTY PRACTICE FOUNDATION INC BOSTON UNIVERSITY DERMATOLOGY INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RHODA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-638-7249
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY ST, SUITE 8B
Practice Address - Street 2:SHAPIRO BLDG
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-7420
Practice Address - Fax:617-638-7289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3115042Medicaid
MA110072443AMedicaid
MA9780238Medicaid