Provider Demographics
NPI:1760476360
Name:MEDREK, PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:MEDREK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BAYSTATE HEALTH
Mailing Address - Street 2:3400A MAIN ST
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-0001
Mailing Address - Country:US
Mailing Address - Phone:413-794-2176
Mailing Address - Fax:413-794-5751
Practice Address - Street 1:BAYSTATE HEALTH
Practice Address - Street 2:3400A MAIN ST
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-0001
Practice Address - Country:US
Practice Address - Phone:413-794-2176
Practice Address - Fax:413-794-5751
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72091207P00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3067327Medicaid
MAE36402Medicare UPIN
MAJ10321Medicare ID - Type Unspecified