Basic Information
| Provider Information | |||||||||
| NPI: | 1710939350 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIONEER VALLEY SURGICAL ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 789 | ||||||||
| Address2: | |||||||||
| City: | LUDLOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010560789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135091000 | ||||||||
| FaxNumber: | 4135091003 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEDICAL CENTER DR STE 404 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137363163 | ||||||||
| FaxNumber: | 4137330206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | ALEXANDER | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4137363163 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 110072435A | 05 | MA | MEDICAID | M16525 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER |