1013133628 NPI number — RICHARD SIAHAAN M.D.

Table of content: RICHARD SIAHAAN M.D. (NPI 1013133628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013133628 NPI number — RICHARD SIAHAAN M.D.

Organization/Personal Information

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

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:
1013133628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 COTTAGE GROVE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06002-3170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-242-0034
Provider Business Mailing Address Fax Number:
860-242-3301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
421 COTTAGE GROVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06002-3170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-242-0034
Provider Business Practice Location Address Fax Number:
860-242-3301
Provider Enumeration Date:
04/18/2007

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:  24303 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 024303 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 004263612 . This is a "CHN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0V0438 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 7294618 . This is a "CIGNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 704554 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004263612 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 369877 . This is a "WELLCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 427750 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 80705 . This is a "GREATWEST" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 010024303CT01 . This is a "BLUESHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 514837 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P3592661 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1751515 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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