Provider Demographics
NPI:1548206626
Name:PIONEER VALLEY NEPHROLOGY, PC
Entity type:Organization
Organization Name:PIONEER VALLEY NEPHROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-787-0090
Mailing Address - Street 1:300 STAFFORD ST
Mailing Address - Street 2:SUITE 161
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-3581
Mailing Address - Country:US
Mailing Address - Phone:413-787-0090
Mailing Address - Fax:413-787-0089
Practice Address - Street 1:300 STAFFORD ST
Practice Address - Street 2:SUITE 161
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3581
Practice Address - Country:US
Practice Address - Phone:413-787-0090
Practice Address - Fax:413-787-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003109932Medicaid
MA9709312Medicaid
MAM17055OtherBCBS GROUP NUMBER
CTC02760Medicare ID - Type UnspecifiedCT GROUP NUMBER
MA9709312Medicaid