Basic Information
| Provider Information | |||||||||
| NPI: | 1770750226 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYSTATE MEDICAL PRACTICE, INC | ||||||||
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| OtherOrganizationName: | BAYSTATE/BMP ART/IVF | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 280 CHESTNUT ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137945700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 759 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137945700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 10/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | CREMONTI | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR MEDICAL STAFF SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4137945508 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VE0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Reproductive Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | M16667 | 01 | MA | BC BS GROUP NUMBER | OTHER |