Provider Demographics
NPI:1447460654
Name:WESTERN MASS MEDICAL GROUP, PC
Entity type:Organization
Organization Name:WESTERN MASS MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:WETSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-788-6139
Mailing Address - Street 1:100 WASON AVENUE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107
Mailing Address - Country:US
Mailing Address - Phone:413-788-6139
Mailing Address - Fax:413-737-1549
Practice Address - Street 1:100 WASON AVENUE
Practice Address - Street 2:SUITE 230
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107
Practice Address - Country:US
Practice Address - Phone:413-788-6139
Practice Address - Fax:413-737-1549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45121261QP2300X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA68230Medicare UPIN
MANP1578Medicare UPIN
MAD26418Medicare UPIN
MAE56637Medicare UPIN
A68230Medicare UPIN
MAM20760Medicare PIN