Healthcare Provider Details

I. General information

NPI: 1093871261
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:
Mailing address:
  • Phone: 413-794-5700
  • Fax: 413-794-1629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry 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