1124000294 NPI number — ELIZABETH M LIDSTONE JAYANATH MD

Table of content: ELIZABETH M LIDSTONE JAYANATH MD (NPI 1124000294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124000294 NPI number — ELIZABETH M LIDSTONE JAYANATH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIDSTONE JAYANATH
Provider First Name:
ELIZABETH
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124000294
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
326 NICHOLS ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FITCHBURG
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01420-1914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-878-8100
Provider Business Mailing Address Fax Number:
978-878-8418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 CONNORS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-410-6100
Provider Business Practice Location Address Fax Number:
978-410-6109
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  156974 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: J19766 . This is a "BLUE SHIELD HMO BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: J19766 . This is a "BLUE CARE ELECT" identifier . This identifiers is of the category "OTHER".
  • Identifier: J19766 . This is a "BLUE SHIELD INDEMNITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1836498 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7521481 . This is a "CIGNA HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3188787 . This is a "MEDICAID/WELFARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3188787 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33367 . This is a "CHILDRENS MED SECURITY PL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33367 . This is a "HEALTHY START" identifier . This identifiers is of the category "OTHER".
  • Identifier: 42389 . This is a "FALLON COMMUNITY HLTH PL" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA1277 . This is a "HARVARD PILGRIM HEALTHCAR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "PRIVATE HEALTHCARE SYSTEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3188787 . This is a "MEDICAID PCC" identifier . This identifiers is of the category "OTHER".
  • Identifier: A29170 . This is a "MEDICARE B" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "ONE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7575320 . This is a "AETNA/US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 784154 . This is a "MVP HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "HEALTHCARE VALUE MNGMENT" identifier . This identifiers is of the category "OTHER".




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