Provider Demographics
NPI:1386883767
Name:PREVENTIVE MEDICINE ASSOCIATES
Entity type:Organization
Organization Name:PREVENTIVE MEDICINE ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DELONG
Authorized Official - Suffix:
Authorized Official - Credentials:MM, RHIA
Authorized Official - Phone:413-222-7711
Mailing Address - Street 1:5 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301-2909
Mailing Address - Country:US
Mailing Address - Phone:413-774-2623
Mailing Address - Fax:413-774-3244
Practice Address - Street 1:5 PARK ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301-2909
Practice Address - Country:US
Practice Address - Phone:413-774-2623
Practice Address - Fax:413-774-3244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty