1730202938 NPI number — NEW ENGLAND CENTER FOR FUNCTIONAL MEDICINE PC

Table of content: (NPI 1730202938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730202938 NPI number — NEW ENGLAND CENTER FOR FUNCTIONAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW ENGLAND CENTER FOR FUNCTIONAL 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'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:
1730202938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-205-1200
Provider Business Mailing Address Fax Number:
413-205-1220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-205-1200
Provider Business Practice Location Address Fax Number:
413-205-1220
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KEROACK
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
R
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
413-205-1200

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RB0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M19415 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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