Provider Demographics
NPI:1619900172
Name:PIONEER VALLEY RADIATION ONCOLOGY, PC
Entity Type:Organization
Organization Name:PIONEER VALLEY RADIATION ONCOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ACKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-794-9338
Mailing Address - Street 1:PO BOX 4110
Mailing Address - Street 2:DEPT 1410
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01888-4110
Mailing Address - Country:US
Mailing Address - Phone:413-794-9338
Mailing Address - Fax:
Practice Address - Street 1:3350 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1112
Practice Address - Country:US
Practice Address - Phone:413-794-9175
Practice Address - Fax:413-794-5153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74050174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9783679Medicaid
MAM16963OtherBLUE CROSS BLUE SHIELD
MAM20534OtherMEDICARE PTAN