Healthcare Provider Details

I. General information

NPI: 1235395856
Provider Name (Legal Business Name): PREVENTIVE MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2008
Last Update Date: 08/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 WILLIAMS ST SUITE 10
PITTSFIELD MA
01201-7463
US

IV. Provider business mailing address

740 WILLIAMS ST SUITE 10
PITTSFIELD MA
01201-7463
US

V. Phone/Fax

Practice location:
  • Phone: 413-214-7486
  • Fax:
Mailing address:
  • Phone: 413-214-7486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY J DELONG
Title or Position: CREDENTIALING MANAGER
Credential: MM, RHIA
Phone: 413-222-7711