Provider Demographics
NPI:1295289056
Name:BAYSTATE NORTHERN EDGE ADULT MEDICINE
Entity type:Organization
Organization Name:BAYSTATE NORTHERN EDGE ADULT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-794-8777
Mailing Address - Street 1:3400 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1003
Mailing Address - Country:US
Mailing Address - Phone:413-799-8777
Mailing Address - Fax:413-799-8266
Practice Address - Street 1:3400 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-1003
Practice Address - Country:US
Practice Address - Phone:413-799-8777
Practice Address - Fax:413-799-8266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA48101305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service