Basic Information
| Provider Information | |||||||||
| NPI: | 1477534675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPATZ | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 460 TOTTEN POND RD | ||||||||
| Address2: | C O MZI | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818909933 | ||||||||
| FaxNumber: | 7818909950 | ||||||||
| Practice Location | |||||||||
| Address1: | 88 WASHINGTON ST | ||||||||
| Address2: | ATTN EMERGENCY DEPT | ||||||||
| City: | TAUNTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027802465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088287108 | ||||||||
| FaxNumber: | 5088287158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 51313 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | J09080 | 01 | MA | BCBS | OTHER | 3054781 | 05 | MA | MEDICAID | 437034 | 01 | MA | HPHC | OTHER | 713953 | 01 | MA | TUFTS | OTHER |