1770725384 NPI number — ALICIA STANTON MD, PA

Table of content: (NPI 1770725384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770725384 NPI number — ALICIA STANTON MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALICIA STANTON MD, PA
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:
BODYLOGICMD OF HARTFORD
Provider Other Organization Name Type Code:
3
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:
1770725384
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 WOODLAND ST
Provider Second Line Business Mailing Address:
SUITE 121
Provider Business Mailing Address City Name:
HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06105-4318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-959-2758
Provider Business Mailing Address Fax Number:
860-432-5876

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
195 W CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06040-4858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-959-2758
Provider Business Practice Location Address Fax Number:
860-432-5876
Provider Enumeration Date:
03/27/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STANTON
Authorized Official First Name:
ALICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
800-959-2758

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  033768 , 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)