1124013792 NPI number — PETER SHIMKIN MD

Table of content: PETER SHIMKIN MD (NPI 1124013792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124013792 NPI number — PETER SHIMKIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIMKIN
Provider First Name:
PETER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1124013792
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9135
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLINE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02446-9135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-927-0002
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
56 QUARRY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRUMBULL
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06611-4874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-696-6125
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  014936 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001149368 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300124895 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0086989 . This is a "AETNA CT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: ANC1162 . This is a "OXFORD HEALTH PLANS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: OV9113 . This is a "HEALTH NET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 500HBX051CT01 . This is a "BCBS CT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 061613357 . This is a "CIGNA CT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2069098 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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