Provider Demographics
NPI:1548589047
Name:FENWAY COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:FENWAY COMMUNITY HEALTH CENTER, INC
Other - Org Name:SIDNEY BORUM JR. HEALTH CENTER OF FENWAY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANACE & ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIEBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-927-6173
Mailing Address - Street 1:1340 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-4302
Mailing Address - Country:US
Mailing Address - Phone:617-927-6173
Mailing Address - Fax:617-927-5410
Practice Address - Street 1:75 KNEELAND ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1901
Practice Address - Country:US
Practice Address - Phone:617-457-8140
Practice Address - Fax:617-457-8141
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FENWAY COMMUNITY HEALTH CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-24
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4519261QC1500X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110024430FMedicaid