Healthcare Provider Details

I. General information

NPI: 1528221629
Provider Name (Legal Business Name): NORTHEND MEDICAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SUMNER AVE
SPRINGFIELD MA
01108-2321
US

IV. Provider business mailing address

84 LAWRENCE DR
LONGMEADOW MA
01106-1618
US

V. Phone/Fax

Practice location:
  • Phone: 413-241-6152
  • Fax: 413-241-6153
Mailing address:
  • Phone: 413-241-6152
  • Fax: 413-241-6153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number210668
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9738550 / 110080708A
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
IdentifierA3503501
Identifier TypeOTHER
Identifier State
Identifier IssuerGROUP MEMBER: AKINNIYI B. ODUTOLA; NPI 1588629240
# 3
Identifier1915999
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA
# 4
Identifier3036020; 3036024
Identifier TypeOTHER
Identifier State
Identifier IssuerUNITED HEALTH
# 5
Identifier0007987
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerPTAN
# 6
Identifier0045591
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerNEIGHBORHOOD HEALTH PLAN
# 7
Identifier000000049627
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBOSTON MEDICAL CENTER HEALTHNET

VIII. Authorized Official

Name: AKINNIYI BABASOLA ODUTOLA
Title or Position: MEMBER
Credential: M.D.
Phone: 413-241-6152