Provider Demographics
NPI:1457064388
Name:BOSTON MEDICAL CENTER CORPORATION
Entity Type:Organization
Organization Name:BOSTON MEDICAL CENTER CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING AND CREDENTIALING ANALY
Authorized Official - Prefix:
Authorized Official - First Name:EMBELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:OKUNADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-414-0536
Mailing Address - Street 1:20 MAVERICK SQ
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-2335
Mailing Address - Country:US
Mailing Address - Phone:617-569-5800
Mailing Address - Fax:617-568-4756
Practice Address - Street 1:20 MAVERICK SQ
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-2335
Practice Address - Country:US
Practice Address - Phone:617-569-5800
Practice Address - Fax:617-568-4756
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST BOSTON NEIGHBORHOOD HEALTH CENTER CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110022129HMedicaid