Provider Demographics
NPI:1790804623
Name:BETH ISRAEL DEACONESS MEDICAL CENETR
Entity Type:Organization
Organization Name:BETH ISRAEL DEACONESS MEDICAL CENETR
Other - Org Name:BOWDOIN STREET HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:ADELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARGULES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-754-0100
Mailing Address - Street 1:55 MANOR ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-2468
Mailing Address - Country:US
Mailing Address - Phone:617-436-7491
Mailing Address - Fax:
Practice Address - Street 1:230 BOWDOIN ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-1817
Practice Address - Country:US
Practice Address - Phone:617-754-0100
Practice Address - Fax:617-754-0230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA191735261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health