Healthcare Provider Details

I. General information

NPI: 1750562765
Provider Name (Legal Business Name): SPRINGFIELD INTERNATIONAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 KENT ST
BROOKLINE MA
02445-7901
US

IV. Provider business mailing address

760 CHESTNUT ST
SPRINGFIELD MA
01107-1614
US

V. Phone/Fax

Practice location:
  • Phone: 617-383-6567
  • Fax: 617-383-6664
Mailing address:
  • Phone: 413-214-7486
  • Fax: 413-214-7499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PUNYAMURTULA S KISHORE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 617-383-6567