Healthcare Provider Details

I. General information

NPI: 1730263039
Provider Name (Legal Business Name): UROLOGY GROUP OF WESTERN NEW ENGLAND, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 MAIN ST SUITE 103
SPRINGFIELD MA
01107-1145
US

IV. Provider business mailing address

3640 MAIN ST SUITE 103
SPRINGFIELD MA
01107-1145
US

V. Phone/Fax

Practice location:
  • Phone: 413-785-5321
  • Fax: 413-731-7130
Mailing address:
  • Phone: 413-785-5321
  • Fax: 413-731-7130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHAMMAD R MOSTAFAVI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 413-785-5321