1558314997 NPI number — NEUROLOGICAL SPECIALIST, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558314997 NPI number — NEUROLOGICAL SPECIALIST, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROLOGICAL SPECIALIST, 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:
1558314997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2590 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STRATFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06615-5838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
120-337-7598
Provider Business Mailing Address Fax Number:
120-338-0053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
99 HAWLEY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STRATFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06614-1202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-377-4788
Provider Business Practice Location Address Fax Number:
203-380-0531
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRUEDSON
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
203-257-9302

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  038663 , 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: 004084563 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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