Basic Information
| Provider Information | |||||||||
| NPI: | 1194264911 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEANSLATE MEDICAL GROUP OF THE DISTRICT OF COLUMBIA PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 244 MAIN ST | ||||||||
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| City: | NORTHAMPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135842173 | ||||||||
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| Address1: | 244 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NORTHAMPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135842173 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2017 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | MURPHY | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4135842173 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
No ID Information.