Provider Demographics
NPI:1992723639
Name:ADVANCED MEDICAL GROUP
Entity type:Organization
Organization Name:ADVANCED MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONAVITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-732-0088
Mailing Address - Street 1:155 UNION ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-2010
Mailing Address - Country:US
Mailing Address - Phone:413-732-0088
Mailing Address - Fax:
Practice Address - Street 1:155 UNION ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-2010
Practice Address - Country:US
Practice Address - Phone:413-732-0088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60569225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ08214Medicare ID - Type Unspecified