Basic Information
Provider Information | |||||||||
NPI: | 1114904497 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLEITMAN | ||||||||
FirstName: | JAY | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 789 | ||||||||
Address2: |   | ||||||||
City: | LUDLOW | ||||||||
State: | MA | ||||||||
PostalCode: | 010560789 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135091000 | ||||||||
FaxNumber: | 4135091003 | ||||||||
Practice Location | |||||||||
Address1: | 90 CONZ ST | ||||||||
Address2: |   | ||||||||
City: | NORTHAMPTON | ||||||||
State: | MA | ||||||||
PostalCode: | 010603881 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135869100 | ||||||||
FaxNumber: | 4135863379 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2005 | ||||||||
LastUpdateDate: | 06/22/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 52983 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RP1001X | 52983 | MA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | J03304 | 01 | MA | BLUE CROSS | OTHER | 110024051 | 01 | MA | RR MEDICARE | OTHER | 6180264 | 05 | MA |   | MEDICAID |