Basic Information
Provider Information | |||||||||
NPI: | 1093726382 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CANDIB | ||||||||
FirstName: | LUCY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26 QUEEN ST | ||||||||
Address2: | MEDICAL | ||||||||
City: | WORCESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 016102473 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088607700 | ||||||||
FaxNumber: | 5088607929 | ||||||||
Practice Location | |||||||||
Address1: | 26 QUEEN ST | ||||||||
Address2: | MEDICAL | ||||||||
City: | WORCESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 016102473 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088607700 | ||||||||
FaxNumber: | 5088607929 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2006 | ||||||||
LastUpdateDate: | 07/21/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35966 | MA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0001114 | 01 | MA | NHP | OTHER | 0080097 | 01 | MA | EVERCARE-GROUP | OTHER | 1300709 | 01 | MA | CMSP-GROUP | OTHER | 2078639014 | 01 | MA | UNITED HEALTH CARE | OTHER | Y10141 | 01 | MA | BCBS-GROUP | OTHER | 0006767 | 01 | MA | NHP-GROUP | OTHER | 042485308 | 01 | MA | NETWORK HEALTH-GROUP | OTHER | 23617 | 01 | MA | CMSP | OTHER | 99734101 | 01 | MA | NETWORK HEALTH | OTHER | 0105213 | 01 | MA | EVERCARE | OTHER | 1300709 | 05 | MA |   | MEDICAID | 347292 | 01 | MA | CIGNA | OTHER | N01717 | 01 | MA | BCBS | OTHER | 71720 | 01 | MA | HARVARD PILGRIM | OTHER |