Provider Demographics
NPI:1710070313
Name:MASS GENERAL WALTHAM
Entity Type:Organization
Organization Name:MASS GENERAL WALTHAM
Other - Org Name:GENERAL HOSPITAL CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP OF ADMINISTRATION & FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:MASON
Authorized Official - Last Name:BOEMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-724-4537
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:GRB05-ATTENTION KAREN RYLE
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:781-487-4390
Mailing Address - Fax:781-487-4391
Practice Address - Street 1:52 SECOND AVE FL 4
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1127
Practice Address - Country:US
Practice Address - Phone:781-487-4390
Practice Address - Fax:781-487-4391
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GENERAL HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-02
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA0049076261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0447641Medicaid