Healthcare Provider Details

I. General information

NPI: 1215384409
Provider Name (Legal Business Name): ADULT AND GERIATRIC MEDICINE PARTNERS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 LIBERTY ST SUITE 403
SPRINGFIELD MA
01103-1114
US

IV. Provider business mailing address

PO BOX 70323
SPRINGFIELD MA
01107-0323
US

V. Phone/Fax

Practice location:
  • Phone: 413-455-1217
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number76807
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number76807
License Number StateMA

VIII. Authorized Official

Name: VICTORIA PETERS
Title or Position: PRESIDENT
Credential: D.O.
Phone: 413-455-1217