Provider Demographics
NPI:1659533552
Name:SAMUEL GLADSTONE, MD
Entity Type:Organization
Organization Name:SAMUEL GLADSTONE, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GLADSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-253-2300
Mailing Address - Street 1:12 DICKINSON ST
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-2310
Mailing Address - Country:US
Mailing Address - Phone:413-253-2300
Mailing Address - Fax:413-256-0464
Practice Address - Street 1:12 DICKINSON ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-2310
Practice Address - Country:US
Practice Address - Phone:413-253-2300
Practice Address - Fax:413-256-0464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA55035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10248501OtherCIGNA
MA12640OtherHEALTH NEW ENGLAND
MA2358324OtherAETNA
MA706042OtherCONNECTICARE
MA720950OtherTUFTS
MA71777OtherHARVARD PILGRIM
MAJ06871OtherBCBS
MA222909447OtherMULTIPLAN
MA1293872OtherFALLON
000000007610OtherBMC
MA3029671Medicaid
MA720950OtherTUFTS
000000007610OtherBMC
MA706042OtherCONNECTICARE
MA=========OtherPLAN VISTA/NPPN
MA12640OtherHEALTH NEW ENGLAND
MA=========OtherUNICARE
MA222909447OtherMULTIPLAN
MA2358324OtherAETNA