Healthcare Provider Details

I. General information

NPI: 1033275284
Provider Name (Legal Business Name): BAYSTATE MEDICAL PRACTICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

759 CHESTNUT ST
SPRINGFIELD MA
01199-1001
US

IV. Provider business mailing address

280 CHESTNUT ST 2ND FLOOR
SPRINGFIELD MA
01199-1000
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-5700
  • Fax: 413-794-1629
Mailing address:
  • Phone: 413-794-5700
  • Fax: 413-794-1629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 13
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: RANDALL L VAILL JR.
Title or Position: MANAGER PROVIDER ENROLLMENT
Credential:
Phone: 413-794-7976