1255302030 NPI number — DENISE P KLEISTER NP

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255302030 NPI number — DENISE P KLEISTER NP

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

KLEISTER

Provider First Name:

DENISE

Provider Middle Name:

P

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

NP

Provider Gender Code:

F

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:

1255302030

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/26/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

5 NEPONSET ST FL STREET2

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:

01606-2714

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

508-368-5532

Provider Business Mailing Address Fax Number:

508-368-3113

Provider First Line Business Practice Location Address:

123 SUMMER ST

Provider Second Line Business Practice Location Address:

SUITE 150 S

Provider Business Practice Location Address City Name:

WORCESTER

Provider Business Practice Location Address State Name:

MA

Provider Business Practice Location Address Postal Code:

01608-1216

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

508-368-3110

Provider Business Practice Location Address Fax Number:

508-368-3113

Provider Enumeration Date:

01/30/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 363L00000X , with the licence number:  137040 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0328791 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
• Identifier: 53325 . This is a "FALLON COMMUNITY HEALTH P" identifier . This identifiers is of the category "OTHER".
• Identifier: 8301688 . This is a "EVERCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 0328791 . This is a "MEDICAID WELFARE" identifier . This identifiers is of the category "OTHER".
• Identifier: NP9708 . This is a "BLUE CARE ELECT" identifier . This identifiers is of the category "OTHER".
• Identifier: NP9708 . This is a "MEDICARE B" identifier . This identifiers is of the category "OTHER".
• Identifier: NP9708 . This is a "BLUE SHIELD HMO BLUE" identifier . This identifiers is of the category "OTHER".
• Identifier: NP9708 . This is a "BLUE SHIELD INDEMNITY" identifier . This identifiers is of the category "OTHER".
• Identifier: 58263 . This is a "CHILDRENS MEDICAL SECURIT" 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: 042472266 . This is a "THREE RIVERS" identifier . This identifiers is of the category "OTHER".
• Identifier: 58263 . This is a "HEALTHY START" identifier . This identifiers is of the category "OTHER".
• Identifier: AA3630 . This is a "HARVARD PILGRIM HEALTHCAR" identifier . This identifiers is of the category "OTHER".