Basic Information
| Provider Information | |||||||||
| NPI: | 1003806902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYCHOWSKI | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | GREGORY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3640 MAIN ST STE 207 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137330669 | ||||||||
| FaxNumber: | 4137390621 | ||||||||
| Practice Location | |||||||||
| Address1: | 3640 MAIN ST STE 207 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137390669 | ||||||||
| FaxNumber: | 4137390621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 223722 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 223722 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2105276 | 05 | MA | MEDICAID | 470306 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 36483 | 01 | MA | HEALTH NEW ENGLAND | OTHER | J28919 | 01 | MA | BLUE CROSS BLUE SHIELD MA | OTHER |