Healthcare Provider Details

I. General information

NPI: 1275593758
Provider Name (Legal Business Name): INTERNAL MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 WALNUT STREET EXTENSION
AGAWAM MA
01001
US

IV. Provider business mailing address

PO BOX 788 377 WALNUT STREET EXTENSION
AGAWAM MA
01001
US

V. Phone/Fax

Practice location:
  • Phone: 413-786-7217
  • Fax: 413-786-7219
Mailing address:
  • Phone: 413-786-7217
  • Fax: 413-786-7219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LYNN A MCDONALD
Title or Position: COMPTROLLER
Credential:
Phone: 413-786-4700