1942291653 NPI number — SHANNON B. BEAUSOLEIL I MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942291653 NPI number — SHANNON B. BEAUSOLEIL I MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAUSOLEIL
Provider First Name:
SHANNON
Provider Middle Name:
B.
Provider Name Prefix Text:
Provider Name Suffix Text:
I
Provider Credential Text:
MD
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:
1942291653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1216 FARMINGTON AVE STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06107-2673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-236-0331
Provider Business Mailing Address Fax Number:
860-263-8697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1216 FARMINGTON AVE STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06107-2673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-236-0331
Provider Business Practice Location Address Fax Number:
860-263-8697
Provider Enumeration Date:
11/02/2005

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: 207R00000X , with the licence number:  043733 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 043733 , 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: 3352025 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1302469 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 218498 . This is a "CONNECTICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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