1700864097 NPI number — MEDICAL SPECIALISTS OF FAIRFIELD, LLC

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 1700864097 NPI number — MEDICAL SPECIALISTS OF FAIRFIELD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL SPECIALISTS OF FAIRFIELD, LLC
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:
6
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:
1700864097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 POST RD
Provider Second Line Business Mailing Address:
SOUTH LOBBY
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06824-6232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-255-4545
Provider Business Mailing Address Fax Number:
203-254-1191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 MAIN ST
Provider Second Line Business Practice Location Address:
3RD FLR
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06606-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-382-2475
Provider Business Practice Location Address Fax Number:
203-382-2488
Provider Enumeration Date:
01/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REZNIKOFF
Authorized Official First Name:
GLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
203-255-4545

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010013862CT01 . This is a "BCBS CT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004082666 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104363800 . This is a "DEPT OF LABOR" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: S2G58 . This is a "BCBS NY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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