1134188220 NPI number — MR. SAMUEL GLADSTONE MD

Table of content: MR. SAMUEL GLADSTONE MD (NPI 1134188220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134188220 NPI number — MR. SAMUEL GLADSTONE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLADSTONE
Provider First Name:
SAMUEL
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1134188220
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 DICKINSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01002-2310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-253-2300
Provider Business Mailing Address Fax Number:
413-256-0464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 DICKINSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMHERST
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01002-2310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-253-2300
Provider Business Practice Location Address Fax Number:
413-256-0464
Provider Enumeration Date:
03/20/2006

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: 207Q00000X , with the licence number:  55035 , 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: 2358324 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 706042 . This is a "CONNECTICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3029671 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 71777 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 10248501 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J06871 . This is a "BCBSMA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 720950 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000007610 . This is a "BMC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 12640 . This is a "HNE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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