1013086727 NPI number — ILLUME FERTILITY, PLLC

Table of content: (NPI 1013086727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013086727 NPI number — ILLUME FERTILITY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLUME FERTILITY, PLLC
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:
REPRODUCTIVE MEDICINE ASSOCIATES OF CONNECTICUT, PC
Provider Other Organization Name Type Code:
4
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:
1013086727
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
761 MAIN AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
NORWALK
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06851-1080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-750-7400
Provider Business Mailing Address Fax Number:
203-846-9579

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
761 MAIN AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
NORWALK
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06851-1080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-750-7400
Provider Business Practice Location Address Fax Number:
203-846-9579
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANGIERI
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
203-912-3137

Provider Taxonomy Codes

  • Taxonomy code: 207VE0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 753059794 . This is a "TAX IDENTIFICATION NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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