=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093749756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTIN R LULOFF M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 10/29/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 HOSPITAL DR SUITE 207
-----------------------------------------------------
City | BENNINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05201-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-447-3930
-----------------------------------------------------
Fax | 802-447-8539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 74 GORDONS WAY
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-435-5506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 43877
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------