Provider Demographics
NPI:1942605373
Name:CD PRACTICE ASSOCIATES, INC
Entity Type:Organization
Organization Name:CD PRACTICE ASSOCIATES, INC
Other - Org Name:COOLEY DICKINSON MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STACHELEK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:413-582-2653
Mailing Address - Street 1:30 LOCUST ST
Mailing Address - Street 2:COOLEY DICKINSON MEDICAL GROUP
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2052
Mailing Address - Country:US
Mailing Address - Phone:413-582-2898
Mailing Address - Fax:413-582-2958
Practice Address - Street 1:22 ATWOOD DR
Practice Address - Street 2:SUITE 205
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-4272
Practice Address - Country:US
Practice Address - Phone:413-582-2175
Practice Address - Fax:413-923-9322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM15904Medicare PIN