Provider Demographics
NPI:1528221629
Name:NORTHEND MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:NORTHEND MEDICAL ASSOCIATES INC
Other - Org Name:RAINBOW PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AKINNIYI
Authorized Official - Middle Name:BABASOLA
Authorized Official - Last Name:ODUTOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-241-6152
Mailing Address - Street 1:84 LAWRENCE DR
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1618
Mailing Address - Country:US
Mailing Address - Phone:413-241-6152
Mailing Address - Fax:413-241-6153
Practice Address - Street 1:475 SUMNER AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01108-2321
Practice Address - Country:US
Practice Address - Phone:413-241-6152
Practice Address - Fax:413-241-6153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA210668208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9738550 / 110080708AMedicaid
A3503501OtherGROUP MEMBER: AKINNIYI B. ODUTOLA; NPI 1588629240
1915999OtherAETNA
3036020; 3036024OtherUNITED HEALTH
MA0007987OtherPTAN
MA0045591OtherNEIGHBORHOOD HEALTH PLAN
MA000000049627OtherBOSTON MEDICAL CENTER HEALTHNET