Provider Demographics
NPI:1497831523
Name:BOSTON IVF, INC.
Entity Type:Organization
Organization Name:BOSTON IVF, INC.
Other - Org Name:THE SURGERY CENTER OF WALTHAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARKIN
Authorized Official - Suffix:
Authorized Official - Credentials:JD, MBA
Authorized Official - Phone:781-434-6500
Mailing Address - Street 1:130 2ND AVE
Mailing Address - Street 2:THE SURGERY CENTER OF WALTHAM
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1100
Mailing Address - Country:US
Mailing Address - Phone:781-434-6400
Mailing Address - Fax:781-434-6497
Practice Address - Street 1:130 2ND AVE
Practice Address - Street 2:THE SURGERY CENTER OF WALTHAM
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1100
Practice Address - Country:US
Practice Address - Phone:781-434-6400
Practice Address - Fax:781-434-6497
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOSTON IVF, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-31
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4QLZ261QA0006X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1212524Medicaid
MA221033Medicare PIN