1609879543 NPI number — DR. JOHN W ANDREOLI JR. M.D.

Table of content: DR. JOHN W ANDREOLI JR. M.D. (NPI 1609879543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609879543 NPI number — DR. JOHN W ANDREOLI JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDREOLI
Provider First Name:
JOHN
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1609879543
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2007
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:
860-224-6202
Provider Business Mailing Address Fax Number:
860-826-4957

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 KENSINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BRITAIN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06051-3916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-224-6202
Provider Business Practice Location Address Fax Number:
860-826-4957
Provider Enumeration Date:
05/24/2005

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: 207V00000X , with the licence number:  22366 , 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: 010022366CT03 . This is a "BCBS & BCFP PROVIDER ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001223668 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060073 . This is a "HEALTH NET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2236601 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 60916784 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: C01373 . This is a "GHMC GROUP MEDICARE ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 368660 . This is a "WELLCARE MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P369891 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004196095 . This is a "GHMC GROUP MEDICAID ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 01022366 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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