Basic Information
| Provider Information | |||||||||
| NPI: | 1649468299 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLIAMSTOWN MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 197 ADAMS RD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012672930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134588182 | ||||||||
| FaxNumber: | 4134583140 | ||||||||
| Practice Location | |||||||||
| Address1: | 197 ADAMS RD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012672930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134588182 | ||||||||
| FaxNumber: | 4134583140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | JANDL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4134588182 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 2045 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 0358452 | 05 | MA | MEDICAID |