Basic Information
Provider Information | |||||||||
NPI: | 1487865978 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PRIDE-BOONE | ||||||||
FirstName: | JANICE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PRIDE | ||||||||
OtherFirstName: | JANICE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 30 | ||||||||
Address2: |   | ||||||||
City: | GREAT BARRINGTON | ||||||||
State: | MA | ||||||||
PostalCode: | 01230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135289311 | ||||||||
FaxNumber: | 4136440274 | ||||||||
Practice Location | |||||||||
Address1: | 777 NORTH STREET | ||||||||
Address2: | SUITE 305 | ||||||||
City: | PITTSFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 01201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4134998531 | ||||||||
FaxNumber: | 4134998560 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/25/2007 | ||||||||
LastUpdateDate: | 03/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD 40684 | TN | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | MD 62966 | NJ | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | MD 1582941 | NY | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | LA MD 13859R | LA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | MD 11342 | NV | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | G151811 | CA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 281853 | MA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 281853 | 05 | MA |   | MEDICAID | 1436585 | 05 | LA |   | MEDICAID |