Basic Information
| Provider Information | |||||||||
| NPI: | 1912093121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LURIE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LURIE | ||||||||
| OtherFirstName: | JON | ||||||||
| OtherMiddleName: | D | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | DARTMOUTH-HITCHCOCK MEDICAL CENTER | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036508380 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | DARTMOUTH-HITCHCOCK MEDICAL CENTER | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036508380 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 12/07/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 9320 | NH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 80003682 | 05 | NH | MEDICAID | 0RE3682 | 05 | VT | MEDICAID |