1710069455 NPI number — COURTNEY CALANDRO PA

Table of content: COURTNEY CALANDRO PA (NPI 1710069455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710069455 NPI number — COURTNEY CALANDRO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALANDRO
Provider First Name:
COURTNEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HILL
Provider Other First Name:
COURTNEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710069455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
322 E MAIN ST
Provider Second Line Business Mailing Address:
SUITE 1B
Provider Business Mailing Address City Name:
BRANFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06405-3136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-488-7228
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 WHITNEY AVE
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
HAMDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06518-3691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-281-4463
Provider Business Practice Location Address Fax Number:
203-287-2930
Provider Enumeration Date:
10/20/2006

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: 363AM0700X , with the licence number:  001819 , 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: P01260360 . This is a "RR MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 008017868 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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