1275626673 NPI number — STAMFORD GYNECOLOGY PC

Table of content: (NPI 1275626673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275626673 NPI number — STAMFORD GYNECOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAMFORD GYNECOLOGY PC
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:
1275626673
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 MILL RIVER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAMFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-359-3340
Provider Business Mailing Address Fax Number:
203-359-4515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 MILL RIVER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAMFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-359-3340
Provider Business Practice Location Address Fax Number:
203-359-4515
Provider Enumeration Date:
09/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GOODHUE
Authorized Official First Name:
PETER
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MD PRESIDENT
Authorized Official Telephone Number:
203-359-3340

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  9645 , 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: 774778 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: CT0000025 . This is a "SELECT PRO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 022258 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010009645CT01 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: ZP286 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2152738 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".