Basic Information
| Provider Information | |||||||||
| NPI: | 1124000294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIDSTONE JAYANATH | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 326 NICHOLS ROAD | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014201914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788788100 | ||||||||
| FaxNumber: | 9788788418 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 CONNORS STREET | ||||||||
| Address2: | |||||||||
| City: | GARDER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784106100 | ||||||||
| FaxNumber: | 9784106109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 11/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 156974 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | J19766 | 01 | BLUE SHIELD HMO BLUE | OTHER | J19766 | 01 | BLUE CARE ELECT | OTHER | J19766 | 01 | BLUE SHIELD INDEMNITY | OTHER | 1836498 | 01 | FIRST HEALTH | OTHER | 7521481 | 01 | CIGNA HEALTH PLAN | OTHER | 3188787 | 01 | MEDICAID/WELFARE | OTHER | 3188787 | 05 | MA | MEDICAID | 33367 | 01 | CHILDRENS MED SECURITY PL | OTHER | 33367 | 01 | HEALTHY START | OTHER | 42389 | 01 | FALLON COMMUNITY HLTH PL | OTHER | AA1277 | 01 | HARVARD PILGRIM HEALTHCAR | OTHER | 042472266 | 01 | PRIVATE HEALTHCARE SYSTEM | OTHER | 3188787 | 01 | MEDICAID PCC | OTHER | A29170 | 01 | MEDICARE B | OTHER | 042472266 | 01 | ONE HEALTH PLAN | OTHER | 7575320 | 01 | AETNA/US HEALTHCARE | OTHER | 784154 | 01 | MVP HEALTH CARE | OTHER | 042472266 | 01 | HEALTHCARE VALUE MNGMENT | OTHER |