MEDICARE: TRAILSIDE HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1030561	MA
2	363L00000X	Nurse Practitioner	213928	MA
3	207Q00000X	Family Medicine Physician	209410	MA

General Provider Information

NPI Number	:	1497175459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRAILSIDE HEALTH LLC

Provider Business Mailing Address
First Line	:	111 BRIDGE ST
Second Line	:
City	:	SHELBURNE FALLS
State	:	MA
Zip	:	01370-1142
Country	:	US
Telephone Number	:	413-625-6240
Fax Number	:	413-625-6290

Provider Business Practice Location Address
First Line	:	111 BRIDGE ST
Second Line	:
City	:	SHELBURNE FALLS
State	:	MA
Zip	:	01370-1142
Country	:	US
Telephone Number	:	413-625-6240
Fax Number	:	413-625-6290

Authorized Official
Title or Position	:	CEO
Name	:	STEFAN A. TOPOLSKI
Credential	:	MD
Telephone Number	:	413-625-6240

Provider Enumeration Date	:	04/17/2014
Last Update Date	:	04/17/2014

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