Basic Information
Provider Information | |||||||||
NPI: | 1417932542 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | O'CONNELL | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 69 STATE ST | ||||||||
Address2: |   | ||||||||
City: | NORTHAMPTON | ||||||||
State: | MA | ||||||||
PostalCode: | 010603049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135868156 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 69 STATE ST | ||||||||
Address2: |   | ||||||||
City: | NORTHAMPTON | ||||||||
State: | MA | ||||||||
PostalCode: | 010603049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135868156 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2005 | ||||||||
LastUpdateDate: | 07/13/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 153367 | MA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | 153367 | MA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
ID | Type | State | Issuer | Description | 111105 | 01 | MA | HARVARD PILGRIM | OTHER | 3676690 | 01 | MA | AETNA | OTHER | J14723 | 01 | MA | BCBSMA | OTHER | 23890 | 01 | MA | BMC | OTHER | 403137 | 01 | MA | TUFTS | OTHER | 153367 | 01 | MA | CONNECTICARE | OTHER | 7404242 | 01 | MA | CIGNA | OTHER | 20119 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 9734350 | 05 | MA |   | MEDICAID |