Provider Demographics
NPI:1053394395
Name:DAVID CHADBOURNE
Entity type:Organization
Organization Name:DAVID CHADBOURNE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHADBOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-746-4800
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-0789
Mailing Address - Country:US
Mailing Address - Phone:413-509-1000
Mailing Address - Fax:413-509-1003
Practice Address - Street 1:125 LIBERTY ST
Practice Address - Street 2:SUITE 206
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104
Practice Address - Country:US
Practice Address - Phone:413-746-4800
Practice Address - Fax:413-746-4844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18074OtherBLUE CROSS GRP
MA0001676Medicare PIN