Basic Information
| Provider Information | |||||||||
| NPI: | 1043475932 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BERKSHIRE COLON & RECTAL SURGERY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 93 RIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012014147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472859 | ||||||||
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| Practice Location | |||||||||
| Address1: | 777 NORTH ST | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012014147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472859 | ||||||||
| FaxNumber: | 4133466703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 06/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | BRADWAY | ||||||||
| AuthorizedOfficialFirstName: | MARCELLA | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4134472859 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | D04850 | 01 | MA | RAILROAD MEDICARE | OTHER |