Provider Demographics
NPI:1750440277
Name:NORTHERN BERKSHIRE SPORTS MEDICINE INC
Entity type:Organization
Organization Name:NORTHERN BERKSHIRE SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:413-663-5450
Mailing Address - Street 1:40 MAIN STREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:NORTH ADAMS
Mailing Address - State:MA
Mailing Address - Zip Code:01247-3416
Mailing Address - Country:US
Mailing Address - Phone:413-663-5450
Mailing Address - Fax:413-664-8737
Practice Address - Street 1:40 MAIN STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:NORTH ADAMS
Practice Address - State:MA
Practice Address - Zip Code:01247-3416
Practice Address - Country:US
Practice Address - Phone:413-663-5450
Practice Address - Fax:413-664-8737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA053990174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9773398Medicaid
MAM15970OtherBLUE SHIELD GROUP NUMBER
MAM15970OtherBLUE SHIELD GROUP NUMBER