1336172170 NPI number — DR. LOREN ANTHONY LAINE M.D.

Table of content: DR. LOREN ANTHONY LAINE M.D. (NPI 1336172170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336172170 NPI number — DR. LOREN ANTHONY LAINE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAINE
Provider First Name:
LOREN
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1336172170
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 CAMPBELL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06516-2770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-937-3462
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 CAMPBELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-937-3462
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2006

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: 207RG0100X , with the licence number:  G43237 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 1.052363 , 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: 00G432370 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0016910 . This is a "GROUP MEDICAID PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: W11675 . This is a "GROUP MEDICARE PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G432370 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CE1617 . This is a "GROUP RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 100007942 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1356390009 . This is a "GROUP NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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