Provider Demographics
NPI:1922096205
Name:ABBOTT, ALICE MCCORMICK (MD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:MCCORMICK
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:GWYN
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:421 NORTH MAIN
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:MA
Mailing Address - Zip Code:01053
Mailing Address - Country:US
Mailing Address - Phone:413-584-4040
Mailing Address - Fax:413-773-8435
Practice Address - Street 1:421 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053-9764
Practice Address - Country:US
Practice Address - Phone:413-584-4040
Practice Address - Fax:413-773-8435
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78634207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3141691Medicaid
J31132OtherBCBS
MA3141691Medicaid
MAJ31132Medicare ID - Type Unspecified