Basic Information
| Provider Information | |||||||||
| NPI: | 1467883124 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAG GERIATRICS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60907 | ||||||||
| Address2: | |||||||||
| City: | LONGMEADOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011165907 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 770 CONVERSE ST | ||||||||
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| City: | LONGMEADOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011061719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135676213 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2013 | ||||||||
| LastUpdateDate: | 12/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | JAGADEESAN | ||||||||
| AuthorizedOfficialFirstName: | UDAYA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4134263862 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 210498 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.