1679531354 NPI number — MOUNTAIN MEDICINE PC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679531354 NPI number — MOUNTAIN MEDICINE PC

Employer Identification Number (EIN):

Provider Organization Name:

MOUNTAIN MEDICINE PC

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

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:

1679531354

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

10/10/2007

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1565 HANCOCK RD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

WILLIAMSTOWN

Provider Business Mailing Address State Name:

MA

Provider Business Mailing Address Postal Code:

01267

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

413-442-4700

Provider Business Mailing Address Fax Number:

413-442-4711

Provider First Line Business Practice Location Address:

1450 EAST ST STE 6N

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

PITTSFIELD

Provider Business Practice Location Address State Name:

MA

Provider Business Practice Location Address Postal Code:

01201-5319

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

413-442-4700

Provider Business Practice Location Address Fax Number:

413-442-4711

Provider Enumeration Date:

05/03/2006

Authorized Official Last Name:

DAGOSTINO

Authorized Official First Name:

CHRISTINE

Authorized Official Middle Name:

M

Authorized Official Title or Position:

TREASURER

Authorized Official Telephone Number:

413-442-4700

• Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 3183386 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
• Identifier: 8906530002 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
• Identifier: MD0341139AR . This is a "MA CONTROL #" identifier . This identifiers is of the category "OTHER".
• Identifier: 156843 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
• Identifier: 32023 . This is a "HNE" identifier . This identifiers is of the category "OTHER".
• Identifier: J19130 . This is a "MA BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
• Identifier: 3183386 . This is a "MASS HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 111654 . This is a "MVP" identifier . This identifiers is of the category "OTHER".
• Identifier: 11S654 . This is a "MVP/PIN #" identifier . This identifiers is of the category "OTHER".
• Identifier: 16095 . This is a "NHP" identifier . This identifiers is of the category "OTHER".
• Identifier: 3516813 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 000000020879 . This is a "BERKSHIRE HEALTH NET" identifier . This identifiers is of the category "OTHER".
• Identifier: 000000028890 . This is a "BMC HEALTH NET" identifier . This identifiers is of the category "OTHER".
• Identifier: 1006517 . This is a "VT MEDICAID" identifier . This identifiers is of the category "OTHER".
• Identifier: 156843 . This is a "MA LICENSE" identifier . This identifiers is of the category "OTHER".
• Identifier: 3183386 . This is a "MA MEDICAID" identifier . This identifiers is of the category "OTHER".