Provider Demographics
NPI:1457308637
Name:BOSTON UNIVERSITY MALLORY PATHOLOGY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:BOSTON UNIVERSITY MALLORY PATHOLOGY ASSOCIATES, INC.
Other - Org Name:FACULTY PRACTICE FOUNDATION INC BOSTON UNIV MALLORY PATHOLOGY ASSOC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:MPHIL, PHD
Authorized Official - Phone:617-414-5292
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 1:670 ALBANY ST
Practice Address - Street 2:SUITE 304
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-4291
Practice Address - Fax:617-414-5315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110071206BMedicaid
NH3090107Medicaid