1710966676 NPI number — KRISTINE M FONTAINE PT

Table of content: KRISTINE M FONTAINE PT (NPI 1710966676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710966676 NPI number — KRISTINE M FONTAINE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONTAINE
Provider First Name:
KRISTINE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1710966676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
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:
508-856-9510
Provider Business Mailing Address Fax Number:
508-853-1907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 GOLD STAR BLVD
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:
01506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-856-9510
Provider Business Practice Location Address Fax Number:
508-853-1907
Provider Enumeration Date:
01/10/2006

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: 225100000X , with the licence number:  7353 , 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: 042472266 . This is a "HEALTHCARE VALUE MNGEMENT" 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: Y66516 . This is a "BLUE CARE ELECT" 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: AA4052 . This is a "HARVARD PILGRIM HLTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: Y66516 . This is a "BLUE SHIELD INDEMNITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 650017419 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2779432 . This is a "CIGNA HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 785954 . This is a "MVP HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: Y66516 . This is a "BLUE SHIELD HMO BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0318876 . This is a "MEDICAID/WELFARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 44338 . This is a "FALLON COMMUNITY HLTH PLN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5238453 . This is a "AETNA/US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 35481155 . This is a "CIGNA HEALTHSOURCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: Y69458 . This is a "MEDICARE B" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0318876 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042472266 . This is a "THREE RIVERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2779432001 . This is a "COGMA A; OD (REFERRAL #)" identifier . This identifiers is of the category "OTHER".




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