1154302503 NPI number — DR. LAURA DIANE CRAIN MD

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	CRAIN
Provider First Name	:	LAURA
Provider Middle Name	:	DIANE
Provider Name Prefix Text	:	DR.
Provider Name Suffix Text	:
Provider Credential Text	:	MD
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	:	1154302503
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/08/2007
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
NPI Reactivation Date	:

Provider First Line Business Mailing Address	:	264 BEACON ST FL 6
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	BOSTON
Provider Business Mailing Address State Name	:	MA
Provider Business Mailing Address Postal Code	:	021161236
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	6178670343
Provider Business Mailing Address Fax Number	:	6178670002

Provider First Line Business Practice Location Address	:	264 BEACON ST FL 6
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	BOSTON
Provider Business Practice Location Address State Name	:	MA
Provider Business Practice Location Address Postal Code	:	021161236
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	6178670343
Provider Business Practice Location Address Fax Number	:	6178670002
Provider Enumeration Date	:	11/10/2005

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

• Taxonomy code: 2084P0800X , with the licence number:  72368 , registered in the state of MA .

• Identifier: 724238 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "".
• Identifier: J10355 , issued by the state of ( MA ) . This identifiers is of the category "".
• Identifier: E62304 . This identifiers is of the category "".