Provider Demographics
NPI:1881799427
Name:BAYSTATE MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:BAYSTATE MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KERR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:413-794-3178
Mailing Address - Street 1:140 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-1442
Mailing Address - Country:US
Mailing Address - Phone:413-794-9960
Mailing Address - Fax:413-794-9959
Practice Address - Street 1:140 HIGH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1442
Practice Address - Country:US
Practice Address - Phone:413-794-9960
Practice Address - Fax:413-794-9959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA00521243336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0445266Medicaid
MA110020829/BMedicaid
2236316OtherNABP NUMBER
AB7065053OtherDEA NUMBER