Provider Demographics
NPI:1366684433
Name:SUGARLOAF PEDIATRICS, PC
Entity Type:Organization
Organization Name:SUGARLOAF PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-665-9111
Mailing Address - Street 1:2 PARK ST
Mailing Address - Street 2:UNIT 3
Mailing Address - City:SOUTH DEERFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01373-1035
Mailing Address - Country:US
Mailing Address - Phone:413-665-9111
Mailing Address - Fax:413-665-9211
Practice Address - Street 1:2 PARK ST
Practice Address - Street 2:UNIT 3
Practice Address - City:SOUTH DEERFIELD
Practice Address - State:MA
Practice Address - Zip Code:01373-1035
Practice Address - Country:US
Practice Address - Phone:413-665-9111
Practice Address - Fax:413-665-9211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205161208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0103616Medicaid
MA0103616Medicaid