Provider Demographics
NPI:1801938014
Name:TRUSTEES OF TUFTS COLLEGE
Entity type:Organization
Organization Name:TRUSTEES OF TUFTS COLLEGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GATELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-636-6505
Mailing Address - Street 1:1 KNEELAND ST
Mailing Address - Street 2:DHS-646
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1527
Mailing Address - Country:US
Mailing Address - Phone:617-636-6510
Mailing Address - Fax:617-636-6780
Practice Address - Street 1:1 KNEELAND ST
Practice Address - Street 2:DHS-646
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1527
Practice Address - Country:US
Practice Address - Phone:617-636-6510
Practice Address - Fax:617-636-6780
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUSTEES OF TUFTS COLLEGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-13
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
228200OtherBLUE CROSS BLUE SHIELD
MA110000011OMedicaid