1043376361 NPI number — MISS MERI LEE GREENWALD PT

Table of content: MISS MERI LEE GREENWALD PT (NPI 1043376361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043376361 NPI number — MISS MERI LEE GREENWALD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENWALD
Provider First Name:
MERI
Provider Middle Name:
LEE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1043376361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
73 MASONS ISLAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYSTIC
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06355-2949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-536-7443
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
168 BOSTON POST RD
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06443-2163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-245-9293
Provider Business Practice Location Address Fax Number:
203-245-2522
Provider Enumeration Date:
12/29/2006

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: 174400000X , with the licence number:  004132 , 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: 080004132CT07 . This is a "ANTHEM" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4229444 . This is a "ORTHONET FOR CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4258761 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1544151 . This is a "FIRST HEALTH/COVENTRY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V8207 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P819154 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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