Provider Demographics
NPI:1972762011
Name:ST ELIZABETHS MEDICAL CENTER
Entity Type:Organization
Organization Name:ST ELIZABETHS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:UNTERBORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-789-3000
Mailing Address - Street 1:736 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1959 COMMONWEALTH AVE
Practice Address - Street 2:APT 1
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-5924
Practice Address - Country:US
Practice Address - Phone:617-930-3225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232553282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital