Healthcare Provider Details

I. General information

NPI: 1629358767
Provider Name (Legal Business Name): THE CHILDREN'S HEART CENTER OF WESTERN MASSACHUSETTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2011
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1754 NORTHAMPTON ST
HOLYOKE MA
01040-1947
US

IV. Provider business mailing address

1754 NORTHAMPTON ST
HOLYOKE MA
01040-1947
US

V. Phone/Fax

Practice location:
  • Phone: 413-315-3117
  • Fax: 662-292-7678
Mailing address:
  • Phone: 413-315-3117
  • Fax: 413-585-5122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number237999
License Number StateMA

VIII. Authorized Official

Name: DR. MICHAEL WILLERS
Title or Position: DIRECTOR
Credential: M.D.
Phone: 413-315-3117