1497866107 NPI number — EDWARD G MCKIERNAN IV RPT

Table of content: EDWARD G MCKIERNAN IV RPT (NPI 1497866107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497866107 NPI number — EDWARD G MCKIERNAN IV RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKIERNAN
Provider First Name:
EDWARD
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
IV
Provider Credential Text:
RPT
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:
1497866107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 TECHNOLOGY DR
Provider Second Line Business Mailing Address:
STE A200
Provider Business Mailing Address City Name:
TRUMBULL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06611-6338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-268-5801
Provider Business Mailing Address Fax Number:
203-452-3688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 TECHNOLOGY DR
Provider Second Line Business Practice Location Address:
STE A200
Provider Business Practice Location Address City Name:
TRUMBULL
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06611-6338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-268-5801
Provider Business Practice Location Address Fax Number:
203-452-3688
Provider Enumeration Date:
08/31/2006

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: 225100000X , with the licence number:  004917 , 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: 3918034 . This is a "AETNA PIN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V5288 . This is a "HEALTH NET PIN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 3515548 . This is a "CIGNA PIN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: A2983697 . This is a "OXFORD PIN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 080004917CT04 . This is a "ANTHEM BCBS PIN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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