Basic Information
| Provider Information | |||||||||
| NPI: | 1962460634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | HAROLD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472752 | ||||||||
| FaxNumber: | 4134966836 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 NORTH ST | ||||||||
| Address2: | RENAL DIALYSIS | ||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472764 | ||||||||
| FaxNumber: | 4134472765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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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 | 0320000487 | VT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 80111 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 3128466 | 05 | MA | MEDICAID |