Provider Demographics
NPI:1275690380
Name:BAYSTATE MEDICAL PRACTICES, INC
Entity Type:Organization
Organization Name:BAYSTATE MEDICAL PRACTICES, INC
Other - Org Name:BMP, DEPT OF PATHOLOGY
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:2007-01-02
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion MedicineGroup - Multi-Specialty
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical PathologyGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Multi-Specialty
No207ZM0300XAllopathic & Osteopathic PhysiciansPathologyMedical MicrobiologyGroup - Multi-Specialty
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathologyGroup - Multi-Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM14271Medicare PIN