Organization
BOSTON FOOD ALLERGY CENTER, STEWARD HEALTHCARE NETWORK
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SHAUN WHITE (CREDENTIALING MANAGER)
(502) 244-9859
Entity
Organization
Contact information
Practice address
65 HARRISON AVE, SUITE 201, BOSTON, MA 02111-1924
(617) 636-8858
(617) 636-8826
Mailing address
1 NASSAU ST, UNIT 1906, BOSTON, MA 02111-1542
(617) 636-8858
(617) 636-8826
Taxonomy
Speciality
Code
Description
License number
State
207K00000X
Allergy & Immunology Physician
Primary
230907
MA
207RG0100X
Gastroenterology Physician
230907
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110085164A - INDIV
—
MA
05
—
110109748A
—
MA
01
—
230907
PROVIDER LICENSE
MA
Enumeration date
07/27/2016
Last updated
07/27/2016
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