1235139130 NPI number — MARYBETH S KELLY PAC

Table of content: MARYBETH S KELLY PAC (NPI 1235139130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235139130 NPI number — MARYBETH S KELLY PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
MARYBETH
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARKHAM
Provider Other First Name:
MARYBETH
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235139130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 SPRINGFIELD RD
Provider Second Line Business Mailing Address:
SUITE 1 FAMILY MEDICINE ASSOC
Provider Business Mailing Address City Name:
WESTFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-562-5173
Provider Business Mailing Address Fax Number:
413-562-1716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 SPRINGFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 1 FAMILY MEDICINE ASSOC
Provider Business Practice Location Address City Name:
WESTFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-562-5173
Provider Business Practice Location Address Fax Number:
413-562-1716
Provider Enumeration Date:
07/21/2005

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: 363A00000X , with the licence number:  1150 , 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: 011500 . This is a "CONNECTICARE OF MA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21237210422 . This is a "BEECH STREET" identifier . This identifiers is of the category "OTHER".