Basic Information
| Provider Information | |||||||||
| NPI: | 1053379248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WESTON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | AGAWAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010011838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137896800 | ||||||||
| FaxNumber: | 4135987876 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | AGAWAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010011838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137896800 | ||||||||
| FaxNumber: | 4135987876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 82092 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 82092 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 110057167/A | 05 | MA | MEDICAID |