Basic Information
| Provider Information | |||||||||
| NPI: | 1235300377 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRVIEW HOSPITAL DIALYSIS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1172 | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012021172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472000 | ||||||||
| FaxNumber: | 4134472803 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012301904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4138549910 | ||||||||
| FaxNumber: | 4138549911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2008 | ||||||||
| LastUpdateDate: | 01/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | RODOWICZ | ||||||||
| AuthorizedOfficialFirstName: | DARLENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4134472000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAIRVIEW HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 2052 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 0373 | 01 | NY | MVP | OTHER | 1200542 | 05 | MA | MEDICAID | 20850 | 01 | MA | BMC HEALTH NET PLAN | OTHER | 900245 | 01 | MA | TUFTS HEALTH PLAN OUTPT | OTHER | 221302 | 01 | KY | HUMANA | OTHER | 6300460 | 01 | AETNA | OTHER | 10005803 | 01 | NY | CDPHP | OTHER | 2222003801 | 01 | MA | BLUE CROSS INPATIENT | OTHER | 900038 | 01 | MA | HARVARD PILGRIM | OTHER | HO4359 | 01 | CT | OXFORD HEALTH PLANS | OTHER | 905627 | 01 | MA | TUFTS HEALTH PLAN INPT | OTHER | 1001728 | 05 | MA | MEDICAID | 12257 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 2222003830 | 01 | MA | BLUE CROSS SDC | OTHER | 2222003810 | 01 | MA | BLUE CROSS OUTPATIENT | OTHER | 992756 | 01 | CT | CONNECTICARE | OTHER | 220038 | 01 | MA | UNICARE MA EMPLOYEE GIC | OTHER |