Provider Demographics
NPI:1497175459
Name:TRAILSIDE HEALTH LLC
Entity Type:Organization
Organization Name:TRAILSIDE HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEFAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:TOPOLSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-625-6240
Mailing Address - Street 1:111 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:01370-1142
Mailing Address - Country:US
Mailing Address - Phone:413-625-6240
Mailing Address - Fax:413-625-6290
Practice Address - Street 1:111 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SHELBURNE FALLS
Practice Address - State:MA
Practice Address - Zip Code:01370-1142
Practice Address - Country:US
Practice Address - Phone:413-625-6240
Practice Address - Fax:413-625-6290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10305611041C0700X
MA209410207Q00000X
MA213928363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty