Basic Information
Provider Information | |||||||||
NPI: | 1326015983 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FIALLO | ||||||||
FirstName: | VIRIATO | ||||||||
MiddleName: | MANUEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 10417 | ||||||||
Address2: |   | ||||||||
City: | HOLYOKE | ||||||||
State: | MA | ||||||||
PostalCode: | 010412017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135400150 | ||||||||
FaxNumber: | 4135400159 | ||||||||
Practice Location | |||||||||
Address1: | 2 MEDICAL CENTER DR | ||||||||
Address2: | SUITE # 404 | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 011071270 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137363163 | ||||||||
FaxNumber: | 4137330206 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2006 | ||||||||
LastUpdateDate: | 03/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 70766 | MA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1704472 | 01 |   | UNITED HEALTH CARE | OTHER | J09106 | 01 |   | BLUE CROSS BLUE SHIELD | OTHER | 2033361 | 01 |   | AETNA | OTHER | 484559 | 01 |   | CCARE | OTHER | 3054659 | 05 | MA |   | MEDICAID | 4848319-004 | 01 |   | CIGNA | OTHER | 12337 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 715050 | 01 |   | TUFTS HEALTH INSURANCE | OTHER | 801591 | 01 |   | HAVARD PILGRIM HEALTH CAR | OTHER |