1386782290 NPI number — DR. ANDREW MOYER GRUNEBAUM PH.D.

Table of content: DR. ANDREW MOYER GRUNEBAUM PH.D. (NPI 1386782290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386782290 NPI number — DR. ANDREW MOYER GRUNEBAUM PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRUNEBAUM
Provider First Name:
ANDREW
Provider Middle Name:
MOYER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.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:
1386782290
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 SPOKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBRIDGE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06525-1132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-393-0817
Provider Business Mailing Address Fax Number:
203-357-9030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
999 SUMMER ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
STAMFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06905-5546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-324-9712
Provider Business Practice Location Address Fax Number:
203-357-9030
Provider Enumeration Date:
02/02/2007

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: 103TC0700X , with the licence number:  001760 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X , with the licence number: 001760 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4309291 . This is a "AETNA PIN NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060001760CT01 . This is a "ANTHEM BLUE CROSS ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 6893902 . This is a "GHI-VALUEOPTIONS ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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