Provider Demographics
NPI:1750453601
Name:MARK BIRRELL
Entity Type:Organization
Organization Name:MARK BIRRELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BIRRELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:413-572-0003
Mailing Address - Street 1:26 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:LENOX
Mailing Address - State:MA
Mailing Address - Zip Code:01240-2324
Mailing Address - Country:US
Mailing Address - Phone:413-637-4427
Mailing Address - Fax:
Practice Address - Street 1:555 HUBBARD AVE
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-3876
Practice Address - Country:US
Practice Address - Phone:413-442-2848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3653152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0356328Medicaid
MA451658Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMER
MA0356328Medicaid