MEDICARE: NORTHEND MEDICAL ASSOCIATES INC

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	208000000X	Pediatrics Physician	210668	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	A3503501	OTHER		GROUP MEMBER: AKINNIYI B. ODUTOLA; NPI 1588629240
3	1915999	OTHER		AETNA
4	3036020; 3036024	OTHER		UNITED HEALTH
5	0007987	OTHER	MA	PTAN
6	0045591	OTHER	MA	NEIGHBORHOOD HEALTH PLAN
7	000000049627	OTHER	MA	BOSTON MEDICAL CENTER HEALTHNET

General Provider Information

NPI Number	:	1528221629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEND MEDICAL ASSOCIATES INC

Provider Business Mailing Address
First Line	:	84 LAWRENCE DR
Second Line	:
City	:	LONGMEADOW
State	:	MA
Zip	:	01106-1618
Country	:	US
Telephone Number	:	413-241-6152
Fax Number	:	413-241-6153

Provider Business Practice Location Address
First Line	:	475 SUMNER AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MA
Zip	:	01108-2321
Country	:	US
Telephone Number	:	413-241-6152
Fax Number	:	413-241-6153

Authorized Official
Title or Position	:	MEMBER
Name	:	AKINNIYI BABASOLA ODUTOLA
Credential	:	M.D.
Telephone Number	:	413-241-6152

Provider Enumeration Date	:	07/08/2008
Last Update Date	:	03/11/2016

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