NPIMap

Organization Active NPI

Fenway Community Health Center, Inc

Doing business as Fenway Health

  • Federally Qualified Health Center (FQHC)
  • Boston, MA
National Provider Identifier
1003804725
Registry record updated Jul 7, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
4519 Issued in MA
Legal business name
FENWAY COMMUNITY HEALTH CENTER, INC
Doing business as
Fenway Health
Practice address
1340 Boylston St
Boston, MA 02215-4302
Phone
(617) 927-4880
NPI assigned
Oct 6, 2005
Last updated
Jul 7, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 7, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jeff Lieberman
Title
VP Finance & Administration
Phone
(617) 927-6173

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 4519 MA Primary
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X 4519 MA

Addresses

Primary practice location

1340 Boylston St
Boston, MA 02215-4302

Mailing address

1340 Boylston St
Boston, MA 02215-4302
Phone (617) 927-4880

Other identifiers 1

IdentifierTypeStateIssuer
1303546MedicaidMA

Other names 1

  • Fenway Health Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040508000030 MA Part B Supplier - Clinic/Group Practice 0941299655 Receives reassigned benefits from 90 practitioners
Practice locations: Boston, MA
O20050126000196 MA Part A Provider - Federally Qualified Health Center (FQHC) 0941299655 Practice locations: Boston, MA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1003804725. Details of each certification follow.

Federally qualified health center certification: CCN 221867

Legal name
FENWAY COMMUNITY HEALTH CENTER, INC
Doing business as
FENWAY HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 12, 2005
Last certification
Apr 12, 2005
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1973 in MA
Enrollment address
1340 Boylston St
Boston, MA 22154302

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Harold Du Four-Anderson Individual Corporate Director Jul 1, 2018
Colin E Gibbons Individual Corporate DirectorBoard Member Jul 1, 2021
David Joseph Davis Individual Corporate Director Jul 1, 2019
Jordina a Shanks Individual Corporate DirectorInterim Ceo Mar 18, 2024
Operational/Managerial ControlInterim Ceo Mar 18, 2024
Jennifer W Chrisler Individual Corporate DirectorBoard Member Jul 1, 2021
Robert Swann Individual Contracted Managing EmployeeAd; Jan 1, 2025
W-2 Managing EmployeeAd; Jan 1, 2025
Operational/Managerial ControlCoo Jan 1, 2025
Jason Levy Individual Contracted Managing EmployeeAd; Mar 1, 2025
W-2 Managing EmployeeAd; Mar 1, 2025
Operational/Managerial ControlCfo Mar 1, 2025
Diane Tucker Individual Corporate DirectorBoard Member Jul 1, 2018

Practitioners & affiliated clinicians

Practitioners 94

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 94

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1128556800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1309996800000",
    "number": "1003804725",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1340 BOYLSTON ST",
            "city": "BOSTON",
            "state": "MA",
            "postal_code": "022154302",
            "telephone_number": "617-927-4880"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1340 BOYLSTON ST",
            "city": "BOSTON",
            "state": "MA",
            "postal_code": "022154302",
            "telephone_number": "617-927-4880"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FENWAY COMMUNITY HEALTH CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-06",
        "last_updated": "2011-07-07",
        "status": "A",
        "authorized_official_last_name": "LIEBERMAN",
        "authorized_official_first_name": "JEFF",
        "authorized_official_title_or_position": "VP FINANCE & ADMINISTRATION",
        "authorized_official_telephone_number": "617-927-6173"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MA",
            "license": "4519",
            "primary": true
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "MA",
            "license": "4519",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1303546",
            "state": "MA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fenway Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Boston, MA

Sources for this page

Verify at the official NPI Registry.