Basic Information
| Provider Information | |||||||||
| NPI: | 1518064427 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLD | ||||||||
| FirstName: | HENRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 291 MOODY ST | ||||||||
| Address2: | |||||||||
| City: | LUDLOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010561246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4136645279 | ||||||||
| FaxNumber: | 4135897554 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 HOSPITAL AVENUE | ||||||||
| Address2: | |||||||||
| City: | NORTH ADAMS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4136645279 | ||||||||
| FaxNumber: | 4135897554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2085R0202X | 39856 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | J07411 | 01 | MA | BC BS | OTHER | 1003886 | 05 | VT | MEDICAID | 3035999 | 05 | MA | MEDICAID |