Provider Demographics
NPI:1306914601
Name:ELM STREET ADULT MEDICINE, P.C.
Entity type:Organization
Organization Name:ELM STREET ADULT MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-586-1100
Mailing Address - Street 1:264 ELM ST
Mailing Address - Street 2:SUITES 10 & 12
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2857
Mailing Address - Country:US
Mailing Address - Phone:413-586-1100
Mailing Address - Fax:413-584-7062
Practice Address - Street 1:264 ELM ST
Practice Address - Street 2:SUITES 10 & 12
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2857
Practice Address - Country:US
Practice Address - Phone:413-586-1100
Practice Address - Fax:413-584-7062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM21901Medicare PIN