Provider Demographics
NPI:1497156392
Name:THE SPIEGEL CENTER
Entity Type:Organization
Organization Name:THE SPIEGEL CENTER
Other - Org Name:ADVANCED FACIAL AESTHETICS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:H
Authorized Official - Last Name:SPIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-566-3223
Mailing Address - Street 1:335 BOYLSTON STREET
Mailing Address - Street 2:FRONT
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459
Mailing Address - Country:US
Mailing Address - Phone:617-566-3223
Mailing Address - Fax:617-566-3220
Practice Address - Street 1:335 BOYLSTON STREET
Practice Address - Street 2:FRONT
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459
Practice Address - Country:US
Practice Address - Phone:617-566-3223
Practice Address - Fax:617-566-3220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207YS0123X
MA205428261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0112020Medicaid