1700898764 NPI number — EAST HARTFORD PEDIATRIC, LLC.

Table of content: (NPI 1700898764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700898764 NPI number — EAST HARTFORD PEDIATRIC, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST HARTFORD PEDIATRIC, 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:
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:
1700898764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 PAUL SPRING RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-676-1135
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
893 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
EAST HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06108-2292
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-289-3047
Provider Business Practice Location Address Fax Number:
860-528-4735
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VENKATESH
Authorized Official First Name:
JAYASHREE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
860-289-3047

Provider Taxonomy Codes

  • Taxonomy code: 172V00000X , with the licence number:  034733 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0200X , with the licence number: 002155 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 008035516 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001347336 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com