Basic Information
| Provider Information | |||||||||
| NPI: | 1114928579 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAY STATE UROLOGISTS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE. 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5084386364 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 NEVINS ST | ||||||||
| Address2: | STE 503 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177821200 | ||||||||
| FaxNumber: | 6177821521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 09/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | MITCHESON | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6177821200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 9723749 | 05 | MA | MEDICAID |