Basic Information
Provider Information | |||||||||
NPI: | 1366087363 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WESTERN MASS PHYSICIAN ASSOCIATES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOLYOKE MEDICAL GROUP WALK-IN CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 262 NEW LUDLOW RD | ||||||||
Address2: |   | ||||||||
City: | CHICOPEE | ||||||||
State: | MA | ||||||||
PostalCode: | 010204324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135342622 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 140 SOUTHAMPTON RD | ||||||||
Address2: |   | ||||||||
City: | WESTFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 010851370 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135405065 | ||||||||
FaxNumber: | 4135333624 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/13/2019 | ||||||||
LastUpdateDate: | 04/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CANDITO | ||||||||
AuthorizedOfficialFirstName: | PHILLIP | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF AMBULATORY SERVICES | ||||||||
AuthorizedOfficialTelephone: | 4135342622 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | VALLEY HEALTH SYSTEMS, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.