=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851966758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC OPHTHALMOLOGY OF WESTERN MASSACHUSETTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2021
-----------------------------------------------------
Last Update Date | 07/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 S BRIDGE DR STE 2D
-----------------------------------------------------
City | AGAWAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01001-2091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-368-2017
-----------------------------------------------------
Fax | 413-774-2120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 S BRIDGE DR STE 2D
-----------------------------------------------------
City | AGAWAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01001-2091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-368-2017
-----------------------------------------------------
Fax | 413-774-2120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. MICHAEL SCOTT ABRAMS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 413-368-2017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0110X
-----------------------------------------------------
Taxonomy Name | Pediatric Ophthalmology and Strabismus Specialist Physician Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------