Basic Information
| Provider Information | |||||||||
| NPI: | 1922009547 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN MASS PHYSICIAN ASSOCIATES INC | ||||||||
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| OtherOrganizationName: | HOLYOKE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 HOSPITAL DR | ||||||||
| Address2: | WESTERN MASS PHYSICIAN ASSOCIATES, INC. | ||||||||
| City: | HOLYOKE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010406606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135333470 | ||||||||
| FaxNumber: | 4135336859 | ||||||||
| Practice Location | |||||||||
| Address1: | 262 NEW LUDLOW RD | ||||||||
| Address2: | |||||||||
| City: | CHICOPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010204324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135342622 | ||||||||
| FaxNumber: | 4135342661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | CANDITO | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF AMBULATORY SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4135342622 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VALLEY HEALTH SYSTEMS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife | 207V00000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | T203 | 01 | HARVARD PILGRIM | OTHER | 004245983 | 05 | CT | MEDICAID | 9770771 | 05 | MA | MEDICAID | CK1182 | 01 | MA | MEDICARE RAILROAD | OTHER | M15781 | 01 | BLUECARE 65 | OTHER | M15781 | 01 | BCBS OF MASS | OTHER |