Provider Demographics
NPI:1578549507
Name:BRIGHAM AND WOMENS PHYSICIANS ORGANIZATION INC
Entity Type:Organization
Organization Name:BRIGHAM AND WOMENS PHYSICIANS ORGANIZATION INC
Other - Org Name:DBA DEPT OF FAULKNER RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-582-1200
Mailing Address - Street 1:111 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-6002
Mailing Address - Country:US
Mailing Address - Phone:617-582-1200
Mailing Address - Fax:
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9725580Medicaid
MA9725580Medicaid