1003120460 NPI number — DR.SUSAN WESTRUP,LLC

Table of content: (NPI 1003120460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003120460 NPI number — DR.SUSAN WESTRUP,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR.SUSAN WESTRUP,LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003120460
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26 LITTLE FOX LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTPORT
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06880-1403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-644-0804
Provider Business Mailing Address Fax Number:
203-227-6212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 BOSTON POST RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06460-2703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-644-0804
Provider Business Practice Location Address Fax Number:
203-227-6212
Provider Enumeration Date:
07/27/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WESTRUP
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-644-0804

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  002050 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: TUV004169-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 27OA00423800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004142882 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".