Provider Demographics
NPI:1740228360
Name:BOSTON UNIVERSITY PLASTIC SURGERY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:BOSTON UNIVERSITY PLASTIC SURGERY ASSOCIATES, INC.
Other - Org Name:FACULTY PRACTICE FOUNDATION BOSTON UNIV PLASTIC SURGERY ASSOC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:INTERIM PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MCANENY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-638-8446
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:617-414-6031
Practice Address - Street 1:720 HARRISON AVE
Practice Address - Street 2:SUITE 9400
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2371
Practice Address - Country:US
Practice Address - Phone:617-638-8419
Practice Address - Fax:617-414-8412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110067571AMedicaid
MA110067571AMedicaid