1114926078 NPI number — LEONARD EDWARD KULICKI M.D.

Table of content: LEONARD EDWARD KULICKI M.D. (NPI 1114926078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114926078 NPI number — LEONARD EDWARD KULICKI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KULICKI
Provider First Name:
LEONARD
Provider Middle Name:
EDWARD
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:
1114926078
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
99 EAST RIVER DRIVE
Provider Second Line Business Mailing Address:
5TH FLOOR
Provider Business Mailing Address City Name:
EAST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06108-7301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-282-0833
Provider Business Mailing Address Fax Number:
860-282-0170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 FOUNDERS PLZ
Provider Second Line Business Practice Location Address:
#300 C/O IPMS
Provider Business Practice Location Address City Name:
EAST HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06108-3212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-282-4137
Provider Business Practice Location Address Fax Number:
860-282-0170
Provider Enumeration Date:
07/21/2005

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: 207LC0200X , with the licence number:  033958 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 033958 , 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: 001339581 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".