1063482339 NPI number — JACQUELINE SPAIN MD

Table of content: JACQUELINE SPAIN MD (NPI 1063482339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063482339 NPI number — JACQUELINE SPAIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPAIN
Provider First Name:
JACQUELINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063482339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6260
Provider Second Line Business Mailing Address:
230 MAPLE ST
Provider Business Mailing Address City Name:
HOLYOKE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01041-6260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-420-2200
Provider Business Mailing Address Fax Number:
413-420-2260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLYOKE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01040-5124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-420-2200
Provider Business Practice Location Address Fax Number:
413-420-2260
Provider Enumeration Date:
01/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  77663 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8339 . This is a "BOSTON HEALTH NET" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0010026 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 976243 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: SPJ18312 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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