1184655706 NPI number — PATHOLOGY CONSULTANTS OF NEW LONDON, P.C.

Table of content: (NPI 1184655706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184655706 NPI number — PATHOLOGY CONSULTANTS OF NEW LONDON, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHOLOGY CONSULTANTS OF NEW LONDON, P.C.
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:
1184655706
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 902
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06504-0902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-397-8000
Provider Business Mailing Address Fax Number:
203-389-1540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 MONTAUK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW LONDON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06320-4700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-444-5100
Provider Business Practice Location Address Fax Number:
860-444-3709
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REYES
Authorized Official First Name:
MARIA VICTORIA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-397-8000

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 032344 . This is a "HEALTHNET GROUP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2116927 . This is a "AETNA/US HLTH GROUP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004121133 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 744026 . This is a "CONNECTICARE GROUP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 500HBL160CT01 . This is a "BC/BS GROUP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 3193248 . This is a "CIGNA GROUP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: C009155 . This is a "TRI-CARE/CHAMPUS GROUP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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