Provider Demographics
NPI:1902094568
Name:FAMILY CARE MEDICAL CENTER LABORATORY
Entity Type:Organization
Organization Name:FAMILY CARE MEDICAL CENTER LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DETOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-782-6074
Mailing Address - Street 1:1515 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-1803
Mailing Address - Country:US
Mailing Address - Phone:413-783-9114
Mailing Address - Fax:413-782-0960
Practice Address - Street 1:1515 ALLEN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01118-1803
Practice Address - Country:US
Practice Address - Phone:414-783-9114
Practice Address - Fax:413-782-0960
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:URGENT CARE PHYSICIANS P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2483291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM13659OtherBLUE CROSS/BLUE SHIELD MA