1669433645 NPI number — ELIZABETH A FULLER MD

Table of content: ELIZABETH A FULLER MD (NPI 1669433645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669433645 NPI number — ELIZABETH A FULLER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER
Provider First Name:
ELIZABETH
Provider Middle Name:
A
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:
1669433645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2017
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:
01605-2038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-885-9737
Provider Business Mailing Address Fax Number:
508-885-6139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPENCER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01562-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-885-9737
Provider Business Practice Location Address Fax Number:
508-885-6139
Provider Enumeration Date:
03/30/2006

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: 207Q00000X , with the licence number:  75454 , 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: 1150053 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1669433645 . This is a "BLUE CROSS BLUE SHIELD OF MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "PRIVATE HEALTHCARE SYSTEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: J12908 . This is a "BLUE SHIELD INDEMNITY" 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: 9143201 . This is a "CIGNA HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9900893 . This is a "FALLON COMMUNITY HEALTH P" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4545003 . This is a "AETNA US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA1214 . This is a "HARVARD PILGRIM HEALTHCAR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1669433645 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3104796 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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