Provider Demographics
NPI:1396837001
Name:TOWN OF AGAWAM
Entity Type:Organization
Organization Name:TOWN OF AGAWAM
Other - Org Name:AGAWAM HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-786-0400
Mailing Address - Street 1:36 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-1801
Mailing Address - Country:US
Mailing Address - Phone:413-786-0400
Mailing Address - Fax:413-786-9927
Practice Address - Street 1:36 MAIN ST
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-1801
Practice Address - Country:US
Practice Address - Phone:413-786-0400
Practice Address - Fax:413-786-9927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY11035Medicare PIN