1619186574 NPI number — BRANFORD NORTH BRANFORD PEDIATRICS,PC

Table of content: (NPI 1619186574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619186574 NPI number — BRANFORD NORTH BRANFORD PEDIATRICS,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRANFORD NORTH BRANFORD PEDIATRICS,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:
1619186574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
682 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06405-2907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-481-5591
Provider Business Mailing Address Fax Number:
203-481-5594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
999 FOXON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH BRANFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06471-1287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-484-7334
Provider Business Practice Location Address Fax Number:
203-484-7301
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALDMAN
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-481-5591

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 004174132 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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