1982688214 NPI number — THOMAS J FITZGERALD M.D.

Table of content: THOMAS J FITZGERALD M.D. (NPI 1982688214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982688214 NPI number — THOMAS J FITZGERALD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
THOMAS
Provider Middle Name:
J
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:
1982688214
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 415348
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:
02241-5348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 LAKE AVE N
Provider Second Line Business Practice Location Address:
DEPARTMENT OF RADIATION ONCOLOGY
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01655-0002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-856-5551
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2005

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: 2085R0001X , with the licence number:  52720 , 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: 4485196 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: P00762759 . This is a "RR MEDICARE - SECONDARY SITE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 920001819 . This is a "RR MEDICARE PRIMARY SITE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 110065283A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J0395302 . This is a "MEDICARE SECONDARY SITE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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