1487862801 NPI number — PURANIK FAMILY MEDICAL CENTER LLC

Table of content: (NPI 1487862801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487862801 NPI number — PURANIK FAMILY MEDICAL CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PURANIK FAMILY MEDICAL CENTER 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:
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:
1487862801
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:
546 S BROAD ST STE 2E
Provider Second Line Business Mailing Address:
UNIT 2E
Provider Business Mailing Address City Name:
MERIDEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06450-6601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-237-1054
Provider Business Mailing Address Fax Number:
203-237-9913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
546 S BROAD ST
Provider Second Line Business Practice Location Address:
UNIT 2E
Provider Business Practice Location Address City Name:
MERIDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06450-6600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-237-1054
Provider Business Practice Location Address Fax Number:
203-237-9913
Provider Enumeration Date:
05/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PURANIK
Authorized Official First Name:
UJWALA
Authorized Official Middle Name:
P
Authorized Official Title or Position:
MEMBERLLC
Authorized Official Telephone Number:
203-237-1054

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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