Basic Information
Provider Information | |||||||||
NPI: | 1538452891 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JAY FLEITMAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JAY S. FLEITMAN, MD-SLEEP DISORDERS LAB | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9501 POST OFFICE PARK | ||||||||
Address2: |   | ||||||||
City: | WILBRAHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 010951199 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135091000 | ||||||||
FaxNumber: | 4135091003 | ||||||||
Practice Location | |||||||||
Address1: | 332 PLEASANT ST | ||||||||
Address2: |   | ||||||||
City: | NORTHAMPTON | ||||||||
State: | MA | ||||||||
PostalCode: | 010603917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8775669311 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2011 | ||||||||
LastUpdateDate: | 02/21/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FLEITMAN | ||||||||
AuthorizedOfficialFirstName: | JAY | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4135869100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
ID | Type | State | Issuer | Description | 6180264 | 05 | MA |   | MEDICAID |