1205896560 NPI number — DIANE G FRUIT NP

Table of content: DIANE G FRUIT NP (NPI 1205896560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205896560 NPI number — DIANE G FRUIT NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRUIT
Provider First Name:
DIANE
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1205896560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 PLANTATION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-368-3190
Provider Business Mailing Address Fax Number:
508-368-3985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 SUMMER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-368-3190
Provider Business Practice Location Address Fax Number:
508-368-3985
Provider Enumeration Date:
03/23/2006

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: 363L00000X , with the licence number:  89813 , 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: AA3464 . This is a "HARVARD PILGRIM HEALTHCAR" identifier . This identifiers is of the category "OTHER".
  • Identifier: NP0989 . This is a "BLUE SHIELD INDEMNITY" 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: 381317 . This is a "MVP HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: NP0989 . This is a "BLUE SHIELD HMO BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0324094 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 56649 . This is a "CHILDRENS MEDICAL SECURIT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 57172 . This is a "FALLON COMMUNITY HEALTH P" identifier . This identifiers is of the category "OTHER".
  • Identifier: NP0989 . This is a "MEDICARE B" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0324094 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8301165 . This is a "EVERCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: NP0989 . This is a "BLUE CARE ELECT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "THREE RIVERS" identifier . This identifiers is of the category "OTHER".




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