1710019963 NPI number — PROFESSIONAL RESOURCE GROUP PC

Table of content: (NPI 1710019963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710019963 NPI number — PROFESSIONAL RESOURCE GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL RESOURCE GROUP PC
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:
1710019963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 STORRS RD # 174
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD CENTER
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06250-1638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-456-4604
Provider Business Mailing Address Fax Number:
860-456-1738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 STORRS RD # 174
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD CENTER
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06250-1638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-456-4604
Provider Business Practice Location Address Fax Number:
860-456-1738
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KANABAY
Authorized Official First Name:
GARY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
DIRECTOR PRESIDENT
Authorized Official Telephone Number:
860-456-4604

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , 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: 004398047 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008002985 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004255057 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 620000199 . This is a "MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 008033020 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 297211 . This is a "MHN" identifier . This identifiers is of the category "OTHER".
  • Identifier: C007612 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 004255007 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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