Provider Demographics
NPI: | 1033275284 |
---|---|
Name: | BAYSTATE MEDICAL PRACTICES, INC |
Entity Type: | Organization |
Organization Name: | BAYSTATE MEDICAL PRACTICES, INC |
Other - Org Name: | BMP, DEPT OF PEDIATRICS |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | MANAGER PROVIDER ENROLLMENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | RANDALL |
Authorized Official - Middle Name: | L |
Authorized Official - Last Name: | VAILL |
Authorized Official - Suffix: | JR |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 413-794-7976 |
Mailing Address - Street 1: | 280 CHESTNUT ST |
Mailing Address - Street 2: | 2ND FLOOR |
Mailing Address - City: | SPRINGFIELD |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 01199-1000 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 413-794-5700 |
Mailing Address - Fax: | 413-794-1629 |
Practice Address - Street 1: | 759 CHESTNUT ST |
Practice Address - Street 2: | |
Practice Address - City: | SPRINGFIELD |
Practice Address - State: | MA |
Practice Address - Zip Code: | 01199-1001 |
Practice Address - Country: | US |
Practice Address - Phone: | 413-794-5700 |
Practice Address - Fax: | 413-794-1629 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | BAYSTATE MEDICAL PRACTICES, INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2006-12-29 |
Last Update Date: | 2014-02-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 2080A0000X | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | Group - Multi-Specialty |
No | 2080N0001X | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | Group - Multi-Specialty |
No | 2080P0201X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology | Group - Multi-Specialty |
No | 2080P0202X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | Group - Multi-Specialty |
No | 2080P0203X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | Group - Multi-Specialty |
No | 2080P0204X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | Group - Multi-Specialty |
No | 2080P0205X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | Group - Multi-Specialty |
No | 2080P0206X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | Group - Multi-Specialty |
No | 2080P0207X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | Group - Multi-Specialty |
No | 2080P0208X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | Group - Multi-Specialty |
No | 2080P0214X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | M14272 | Medicare PIN |