1669581922 NPI number — MRS. BRIDGET R LOGAN PT

Table of content: MRS. BRIDGET R LOGAN PT (NPI 1669581922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669581922 NPI number — MRS. BRIDGET R LOGAN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOGAN
Provider First Name:
BRIDGET
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

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:
1669581922
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 466
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06019-0466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-936-2268
Provider Business Mailing Address Fax Number:
860-693-8002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 SPENCER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTED
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06098-1140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-738-5810
Provider Business Practice Location Address Fax Number:
860-738-5820
Provider Enumeration Date:
08/30/2006

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 080005891CT01 . This is a "ANTHEM PROVIDER I.D.#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0112901 . This is a "ORTHONET PROVIDER I.D.#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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