1629150644 NPI number — VERA R KILLIAN PT

Table of content: VERA R KILLIAN PT (NPI 1629150644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629150644 NPI number — VERA R KILLIAN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILLIAN
Provider First Name:
VERA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROWN
Provider Other First Name:
VERA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629150644
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
262 LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDOVER
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06232-1709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-742-1859
Provider Business Mailing Address Fax Number:
860-456-4941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 HIGGINS HWY
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
MANSFIELD CENTER
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06250-1437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-456-3772
Provider Business Practice Location Address Fax Number:
860-456-4941
Provider Enumeration Date:
10/19/2006

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: 225100000X , with the licence number:  006689 , 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: 061503332 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 061503332002 . This is a "TRICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: A2752221 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0014105 . This is a "ORTHONET HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 14105 . This is a "ORTHONET CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: OV7726 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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