Basic Information
| Provider Information | |||||||||
| NPI: | 1881664134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAME | ||||||||
| FirstName: | ELIAS | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | CHICOPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010201969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135943111 | ||||||||
| FaxNumber: | 4135987115 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | CHICOPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010201969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135943111 | ||||||||
| FaxNumber: | 4135987115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 05/05/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 212968 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 212968 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0032451 | 01 | MA | MEIGHBORHOOD HEALTH PLAN | OTHER | 971811 | 01 | MA | NETWORK HEALTH | OTHER | NAJ27356 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 28194 | 01 | MA | BOSTON HEALTH NET | OTHER |