1316036940 NPI number — KERYN J RAUSCH APRN

Table of content: KERYN J RAUSCH APRN (NPI 1316036940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316036940 NPI number — KERYN J RAUSCH APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAUSCH
Provider First Name:
KERYN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1316036940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 KENSINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRITAIN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06051-3916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-224-6231
Provider Business Mailing Address Fax Number:
860-224-6260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 LAKE ST
Provider Second Line Business Practice Location Address:
BLDG. B
Provider Business Practice Location Address City Name:
NEW BRITAIN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06052-1396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-826-4453
Provider Business Practice Location Address Fax Number:
860-826-6219
Provider Enumeration Date:
10/12/2006

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: 363L00000X , with the licence number:  000988 , 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: 080988 . This is a "CONNECTICARE ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 378146 . This is a "WELLCARE MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 40APRN988CT01 . This is a "BCFP MEDICAID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V6209 . This is a "HEALTH NET ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 40APRN988CT01 . This is a "BCBS ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1255448155 . This is a "GHMC NPI" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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