Basic Information
| Provider Information | |||||||||
| NPI: | 1205875515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | CHICOPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010201969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135943111 | ||||||||
| FaxNumber: | 4137898034 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | CHICOPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010201969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135943111 | ||||||||
| FaxNumber: | 4137898034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 02/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 72356 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3075486 | 05 | MA | MEDICAID |