Healthcare Provider Details

I. General information

NPI: 1124000294
Provider Name (Legal Business Name): ELIZABETH M LIDSTONE JAYANATH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 CONNORS STREET
GARDER MA
01440
US

IV. Provider business mailing address

326 NICHOLS ROAD
FITCHBURG MA
01420-1914
US

V. Phone/Fax

Practice location:
  • Phone: 978-410-6100
  • Fax: 978-410-6109
Mailing address:
  • Phone: 978-878-8100
  • Fax: 978-878-8418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number156974
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: