1689801748 NPI number — KRISTINE MACOMBER M.D.

Table of content: KRISTINE MACOMBER M.D. (NPI 1689801748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689801748 NPI number — KRISTINE MACOMBER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACOMBER
Provider First Name:
KRISTINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PATTISON
Provider Other First Name:
KRISTINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689801748
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
345 N MAIN ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
WEST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06117-2515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-561-7222
Provider Business Mailing Address Fax Number:
860-561-7228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
345 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
WEST HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06117-2515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-561-7222
Provider Business Practice Location Address Fax Number:
860-561-7228
Provider Enumeration Date:
06/16/2009

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 052014 , 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: 052014 . This is a "LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".