Provider Demographics
NPI:1619957974
Name:CENTRAL BERKSHIRE GASTROENTEROLOGY, PC
Entity Type:Organization
Organization Name:CENTRAL BERKSHIRE GASTROENTEROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PELLISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-499-8590
Mailing Address - Street 1:777 NORTH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4147
Mailing Address - Country:US
Mailing Address - Phone:413-499-8590
Mailing Address - Fax:413-499-6410
Practice Address - Street 1:777 NORTH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4147
Practice Address - Country:US
Practice Address - Phone:413-499-8590
Practice Address - Fax:413-499-6410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA687342OtherTUFTS HEALTHPLAN
NY02102165Medicaid
NY7787OtherCDPHP
MAM17617OtherBCBSMA
MA9701435Medicaid
D91905Medicare UPIN
B74038Medicare UPIN
MAM20881Medicare ID - Type Unspecified
MAM17617OtherBCBSMA
NY02102165Medicaid