Basic Information
| Provider Information | |||||||||
| NPI: | 1164520169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HYDE | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 86 BLUEBERRY HILL RD | ||||||||
| Address2: | |||||||||
| City: | LONGMEADOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011061660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135673084 | ||||||||
| FaxNumber: | 4137470443 | ||||||||
| Practice Location | |||||||||
| Address1: | 299 CAREW ST | ||||||||
| Address2: | SUITE 419 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011042301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137377951 | ||||||||
| FaxNumber: | 4137470443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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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 | 207RG0100X | 52499 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 6182992 | 05 | MA | MEDICAID |