1306821863 NPI number — DR. JEFFREY ROBERT BREITER M.D.

Table of content: DR. JEFFREY ROBERT BREITER M.D. (NPI 1306821863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306821863 NPI number — DR. JEFFREY ROBERT BREITER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREITER
Provider First Name:
JEFFREY
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
DR.
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:
1306821863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2139 SILAS DEANE HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKY HILL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06067-2336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-257-4131
Provider Business Mailing Address Fax Number:
860-257-4519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 TAMARACK AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SOUTH WINDSOR
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06074-5539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-644-4442
Provider Business Practice Location Address Fax Number:
860-644-1412
Provider Enumeration Date:
12/07/2005

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: 207RG0100X , with the licence number:  021746 , 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: 001217462 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010021746CT01 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: HAS731 . This is a "OXFORD HEALTHCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 054626 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0V8025 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 543542 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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