Basic Information
| Provider Information | |||||||||
| NPI: | 1275690380 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAYSTATE MEDICAL PRACTICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BMP, DEPT OF PATHOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 280 CHESTNUT ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137945700 | ||||||||
| FaxNumber: | 4137941629 | ||||||||
| Practice Location | |||||||||
| Address1: | 759 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137945700 | ||||||||
| FaxNumber: | 4137941629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 02/26/2014 | ||||||||
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| AuthorizedOfficialLastName: | VAILL | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4137947976 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAYSTATE MEDICAL PRACTICES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZB0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZC0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZD0900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZM0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Medical Microbiology | 207ZP0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZN0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Neuropathology | 207ZH0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZC0006X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.