1033311915 NPI number — GOLD STAR PEDIATRICS LLC

Table of content: (NPI 1033311915)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033311915 NPI number — GOLD STAR PEDIATRICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLD STAR PEDIATRICS LLC
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:
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:
1033311915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
495 GOLD STAR HWY
Provider Second Line Business Mailing Address:
STE 120
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06340-6228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-449-8882
Provider Business Mailing Address Fax Number:
860-449-9195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 GOLD STAR HWY
Provider Second Line Business Practice Location Address:
STE 495
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06340-6228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-449-8882
Provider Business Practice Location Address Fax Number:
860-449-9195
Provider Enumeration Date:
06/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLEFELD
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
860-449-8882

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  22070 , 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: 004395530 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004238227 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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