Provider Demographics
NPI:1205900354
Name:BETH ISRAEL DEACONESS MEDICAL CENTER
Entity type:Organization
Organization Name:BETH ISRAEL DEACONESS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION CHIEF
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-667-4916
Mailing Address - Street 1:330 BROOKLINE AVE
Mailing Address - Street 2:HEALTHCARE ASSOCIATES, SHAPIRO 6TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-667-9600
Mailing Address - Fax:617-667-9620
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:HEALTHCARE ASSOCIATES, SHAPIRO 6TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-667-9600
Practice Address - Fax:617-667-9620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73356261Q00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Not Answered282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3070191Medicaid
MA3070191Medicaid
MAE68174Medicare UPIN