1265868558 NPI number — INTEGRATED DERMATOLOGY OF GROTON LLC

Table of content: (NPI 1265868558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265868558 NPI number — INTEGRATED DERMATOLOGY OF GROTON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED DERMATOLOGY OF GROTON 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:
EASTERN CONNECTICUT DERMATOLOGY
Provider Other Organization Name Type Code:
3
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:
1265868558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 EXCHANGE CT STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431-4450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-314-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
481 GOLD STAR HWY STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06340-6702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-445-8020
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
QUEEN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
561-314-2000

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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