Provider Demographics
NPI: | 1366509473 |
---|---|
Name: | BAYSTATE MEDICAL PRACTICES, INC. |
Entity Type: | Organization |
Organization Name: | BAYSTATE MEDICAL PRACTICES, INC. |
Other - Org Name: | BMP, DEPT OF SURGERY |
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? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | Group - Multi-Specialty |
No | 2086S0122X | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | Group - Multi-Specialty |
No | 2086S0127X | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | Group - Multi-Specialty |
No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
No | 2086X0206X | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | Group - Multi-Specialty |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
No | 363LA2100X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | Group - Multi-Specialty |
No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | M14361 | Medicare PIN |