Provider Demographics
NPI:1487865978
Name:PRIDE-BOONE, JANICE (MD)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:PRIDE-BOONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:
Other - Last Name:PRIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 30
Mailing Address - Street 2:
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230
Mailing Address - Country:US
Mailing Address - Phone:413-528-9311
Mailing Address - Fax:413-644-0274
Practice Address - Street 1:777 NORTH STREET
Practice Address - Street 2:SUITE 305
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201
Practice Address - Country:US
Practice Address - Phone:413-499-8531
Practice Address - Fax:413-499-8560
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 40684208000000X
NJMD 62966208000000X
NYMD 1582941208000000X
LALA MD 13859R208000000X
NVMD 11342208000000X
CAG151811208000000X
MA281853208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA281853Medicaid
LA1436585Medicaid
E51396Medicare UPIN