Provider Demographics
NPI:1568493971
Name:BETH ISRAEL DEACONESS MEDICAL CENTER
Entity Type:Organization
Organization Name:BETH ISRAEL DEACONESS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BIDPO- ENROLLMENT &CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGANIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:671-754-8782
Mailing Address - Street 1:330 BROOKLINE AVE
Mailing Address - Street 2:REN 8
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-667-4623
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:REN 8
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-667-4623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106994282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital