Healthcare Provider Details

I. General information

NPI: 1295533206
Provider Name (Legal Business Name): IMPACT PHYSICIAN GROUP MASSACHUSETTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 LOWER WESTFIELD RD
HOLYOKE MA
01040-2747
US

IV. Provider business mailing address

PO BOX 744577
ATLANTA GA
30374-4577
US

V. Phone/Fax

Practice location:
  • Phone: 413-315-4100
  • Fax: 844-440-2328
Mailing address:
  • Phone: 678-967-5599
  • Fax: 844-440-2328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL MILLER
Title or Position: CEO
Credential:
Phone: 678-967-5599