1528221629 NPI number — NORTHEND MEDICAL ASSOCIATES INC

Table of content: (NPI 1528221629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528221629 NPI number — NORTHEND MEDICAL ASSOCIATES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEND MEDICAL ASSOCIATES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1528221629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
84 LAWRENCE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGMEADOW
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01106-1618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-241-6152
Provider Business Mailing Address Fax Number:
413-241-6153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
475 SUMNER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01108-2321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-241-6152
Provider Business Practice Location Address Fax Number:
413-241-6153
Provider Enumeration Date:
07/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ODUTOLA
Authorized Official First Name:
AKINNIYI
Authorized Official Middle Name:
BABASOLA
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
413-241-6152

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  210668 , 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: 9738550 / 110080708A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: A3503501 . This is a "GROUP MEMBER: AKINNIYI B. ODUTOLA; NPI 1588629240" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1915999 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3036020; 3036024 . This is a "UNITED HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0007987 . This is a "PTAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0045591 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000049627 . This is a "BOSTON MEDICAL CENTER HEALTHNET" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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