Basic Information
| Provider Information | |||||||||
| NPI: | 1306822655 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAY S. FLEITMAN | ||||||||
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| 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: | 12/19/2005 | ||||||||
| LastUpdateDate: | 06/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | FLEITMAN | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4135869100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | M17879 | 01 | MA | BLUE CROSS | OTHER |