1154371904 NPI number — MR. GRAEME M LIPPER MD

Table of content: MR. GRAEME M LIPPER MD (NPI 1154371904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154371904 NPI number — MR. GRAEME M LIPPER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIPPER
Provider First Name:
GRAEME
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
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:
1154371904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 TAMARACK AVE
Provider Second Line Business Mailing Address:
ADVANCED DERM CARE PC
Provider Business Mailing Address City Name:
DANBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-797-8990
Provider Business Mailing Address Fax Number:
203-748-7861

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 TAMARACK AVE
Provider Second Line Business Practice Location Address:
ADVANCED DERM CARE PC
Provider Business Practice Location Address City Name:
DANBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06811-4829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-797-8990
Provider Business Practice Location Address Fax Number:
203-748-7861
Provider Enumeration Date:
05/11/2006

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: 207N00000X , with the licence number:  040494 , 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: 001404946 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".