Elizabeth M Lidstone Jayanath, MD
Individual provider Active NPI Pediatrics Physician · Garder, MA
NPI 1124000294 · NPPES record last updated Nov 16, 2015
Key facts
- NPI
- 1124000294
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatrics Physician 208000000X
- License
- 156974 (MA)
- Practice address
- 175 Connors Street
Garder, MA 01440 - Phone
- (978) 410-6100
- Fax
- (978) 410-6109
- NPI assigned
- Nov 15, 2005
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 5
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MA, TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20100308000630 | MA | Practitioner - Pediatric Medicine | 8820133341 | Reassigns benefits to 2 organizations |
| I20230914002877 | TX | Practitioner - Pediatric Medicine | 8820133341 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 156974 | MA | MD | Pediatrics Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| The Fort Defiance Indian Hospital Board, Incorporation | Current |
Accepting new patients | |
| Community Health Connections, Inc. | Current | Accepting new patients | |
| Community Health Connections, Inc. | Current |
Accepting new patients | |
| Community Health Connections, Inc. | Current |
Accepting new patients |
Locations
326 Nichols Rd
Fitchburg, MA 01420
Phone (978) 343-5270
175 Connors St
Gardner, MA 01440
Phone (978) 410-6100
Interoperability endpoints
- elizabeth.lidstonejayanath.p1@direct.chcfhc.nextgenshare.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 156974 | MA | Yes |
Addresses
Primary practice location
175 Connors Street
Garder, MA 01440
Mailing address
326 Nichols Road
Fitchburg, MA 01420-1914
Phone (978) 878-8100
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| J19766 | Other | BLUE SHIELD HMO BLUE | |
| J19766 | Other | BLUE CARE ELECT | |
| J19766 | Other | BLUE SHIELD INDEMNITY | |
| 1836498 | Other | FIRST HEALTH | |
| 7521481 | Other | CIGNA HEALTH PLAN | |
| 3188787 | Other | MEDICAID/WELFARE | |
| 3188787 | Medicaid | MA | |
| 33367 | Other | CHILDRENS MED SECURITY PL | |
| 33367 | Other | HEALTHY START | |
| 42389 | Other | FALLON COMMUNITY HLTH PL | |
| AA1277 | Other | HARVARD PILGRIM HEALTHCAR | |
| 042472266 | Other | PRIVATE HEALTHCARE SYSTEM | |
| 3188787 | Other | MEDICAID PCC | |
| A29170 | Other | MEDICARE B | |
| 042472266 | Other | ONE HEALTH PLAN | |
| 7575320 | Other | AETNA/US HEALTHCARE | |
| 784154 | Other | MVP HEALTH CARE | |
| 042472266 | Other | HEALTHCARE VALUE MNGMENT |
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 16, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.