Provider Demographics
NPI:1639215502
Name:BOSTON EYE SURGERY & LASER CENTER TRUST
Entity Type:Organization
Organization Name:BOSTON EYE SURGERY & LASER CENTER TRUST
Other - Org Name:BOSTON EYE SURGERY & LASER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-314-2672
Mailing Address - Street 1:195 WEST ST FL 2
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1111
Mailing Address - Country:US
Mailing Address - Phone:781-768-5590
Mailing Address - Fax:781-487-5717
Practice Address - Street 1:195 WEST ST FL 2
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1111
Practice Address - Country:US
Practice Address - Phone:781-768-5590
Practice Address - Fax:781-487-5717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110031506BMedicaid