Healthcare Provider Details

I. General information

NPI: 1235144064
Provider Name (Legal Business Name): STAFFORD PEDIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 CAREW ST SUITE 430
SPRINGFIELD MA
01104-2301
US

IV. Provider business mailing address

299 CAREW ST SUITE 430
SPRINGFIELD MA
01104-2301
US

V. Phone/Fax

Practice location:
  • Phone: 413-734-6461
  • Fax: 413-734-4540
Mailing address:
  • Phone: 413-734-6461
  • Fax: 413-734-4540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number36150
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. REGINA KRUCZYNSKA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 413-734-6461