Basic Information
| Provider Information | |||||||||
| NPI: | 1790743755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAGADEESAN | ||||||||
| FirstName: | UDAYA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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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: | 770 CONVERSE ST | ||||||||
| Address2: | JGS ADMINISTRATIVE SERVICES | ||||||||
| City: | LONGMEADOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135676213 | ||||||||
| FaxNumber: | 4135652975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 210498 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 210498 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0193631 | 05 | MA | MEDICAID |