Fenway Community Health Center, Inc

Primary specialty

Community Health Clinic/CenterTaxonomy code 261QC1500X

License

4519 Issued in MA

Legal business name

FENWAY COMMUNITY HEALTH CENTER, INC

Practice address

142 Berkeley St
Boston, MA 02116-5100

Phone

(617) 247-7555

NPI assigned

Apr 21, 2011

Organization subpart

Yes

Parent organization

FENWAY COMMUNITY HEALTH CENTER, INCAs reported in NPPES

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

Authorized official

Name

Mr. Jeffrey M Lieberman

Title

VP Finance & Administration

Phone

(617) 927-6173

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Fenway South End Doing business as

Medicare fee-for-service enrollment

Enrolled in MA

Enrollment records 1

Federally qualified health center certification: CCN 221904

Legal name

FENWAY COMMUNITY HEALTH CENTER, INC

Doing business as

FENWAY SOUTH END

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Jul 14, 2011

Last certification

Jul 14, 2011

Ownership / control type

For profit – corporation

Organization structure

CorporationNon-profit

Incorporated

Jan 19, 1973 in MA

Enrollment address

142 Berkeley Street 2ND FL Ste 203
Fenway South End
Boston, MA 21164608

Other NPIs with the same Medicare PAC ID 2

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

• Fenway Community Health Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Boston, MA
  • NPI 1003804725

  0941299655

  Same PAC ID
• Fenway Community Health Center, Inc

  • Pharmacist
  • Boston, MA
  • NPI 1275647505

  0941299655

  Same PAC ID

Part of

Fenway Comm Health Ctr

Locations

All disclosed owners & managing parties 21

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

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Benjamin T Davis, MD

  • Infectious Disease Physician
  • Boston, MA
  • NPI 1912997537

  Corporate Director

  CMS ownership
• Roxane Gardner, MD

  • Obstetrics & Gynecology Physician
  • Boston, MA
  • NPI 1609851476

  Corporate Director

  CMS ownership
• Michael Anastasios Kramer, DDS

  • Periodontics
  • Sudbury, MA
  • NPI 1053481077

  Corporate Director

  CMS ownership
• Vincent Cordell Smith, MD MPH

  • Neonatal-Perinatal Medicine Physician
  • Boston, MA
  • NPI 1962459289

  Corporate Director

  CMS ownership

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

{
    "created_epoch": "1303344000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1310083200000",
    "number": "1982995197",
    "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": "617-927-6073",
            "fax_number": "617-927-5410"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "142 BERKELEY ST",
            "city": "BOSTON",
            "state": "MA",
            "postal_code": "021165100",
            "telephone_number": "617-247-7555"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FENWAY COMMUNITY HEALTH CENTER, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FENWAY COMMUNITY HEALTH CENTER, INC",
        "enumeration_date": "2011-04-21",
        "last_updated": "2011-07-08",
        "status": "A",
        "authorized_official_last_name": "LIEBERMAN",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "VP FINANCE & ADMINISTRATION",
        "authorized_official_telephone_number": "617-927-6173",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "MA",
            "license": "4519",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "110020739D",
            "state": "MA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fenway South End",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Fenway Community Health Center Inc
• Fenway Community Health Center, Inc
• Fenway Community Health Center, Inc
• Fenway Community Health Center, Inc
• Fenway Community Health Center, Inc
• Fenway Health
• Fenway Hearing Conservatory
• Marguerite Fenwood, LCSW
• Nicholas Feola, PHARMD
• Erin Fera, FNP

• Community Health Clinic/Center in Boston, MA
• Providers in Boston, MA by specialty
• Community Health Clinic/Center in Massachusetts

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.