Healthcare Provider Details

I. General information

NPI: 1912561986
Provider Name (Legal Business Name): MVNE 1 PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 UNION ST
WEST SPRINGFIELD MA
01089
US

IV. Provider business mailing address

136 DWIGHT RD
LONGMEADOW MA
01106
US

V. Phone/Fax

Practice location:
  • Phone: 413-781-0100
  • Fax:
Mailing address:
  • Phone: 413-565-3181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES BRENNAN
Title or Position: MANAGER
Credential:
Phone: 413-565-3180