1093749756 NPI number — MARTIN R LULOFF M.D.

Table of content: MARTIN R LULOFF M.D. (NPI 1093749756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093749756 NPI number — MARTIN R LULOFF M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LULOFF
Provider First Name:
MARTIN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1093749756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
74 GORDONS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-435-5506
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
BENNINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05201-5009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-447-3930
Provider Business Practice Location Address Fax Number:
802-447-8539
Provider Enumeration Date:
07/10/2006

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: 208000000X , with the licence number:  43877 , 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: 12-01279 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 043877 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 20017 . This is a "HEALTHSOURCE(CMHC)" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 451063 . This is a "AETNA/US HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: E45016 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4223701 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 20700 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: B10096001 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2072734 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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