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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X223722MAY Allopathic & Osteopathic PhysiciansInternal Medicine 
208000000X223722MAN Allopathic & Osteopathic PhysiciansPediatrics 

ID Information
IDTypeStateIssuerDescription
47030601MATUFTS HEALTH PLANOTHER
J2891901MABLUE CROSS BLUE SHIELD MAOTHER
3648301MAHEALTH NEW ENGLANDOTHER
210527605MA MEDICAID


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