1558473769 NPI number — MR. THOMAS KUCHARCHIK MD

Table of content: MR. THOMAS KUCHARCHIK MD (NPI 1558473769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558473769 NPI number — MR. THOMAS KUCHARCHIK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUCHARCHIK
Provider First Name:
THOMAS
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1558473769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
635 MAIN ST
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING DPT
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06457-2718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-347-6971
Provider Business Mailing Address Fax Number:
860-638-6601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
481 GOLD STAR HWY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06340-6702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-446-8858
Provider Business Practice Location Address Fax Number:
860-405-2140
Provider Enumeration Date:
09/01/2006

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: 207Q00000X , with the licence number:  25896 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 9785 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 097852 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 761101 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 030897 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: NLP057 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: SC11353402 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 001258961 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010025896CT01 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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