1720194053 NPI number — PROHEALTH PHYSICIANS PC

Table of content: (NPI 1720194053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720194053 NPI number — PROHEALTH PHYSICIANS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROHEALTH PHYSICIANS 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:
1720194053
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 FARM GLEN BLVD
Provider Second Line Business Mailing Address:
PROHEALTH PHYSICIANS
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06032-1981
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-284-5200
Provider Business Mailing Address Fax Number:
860-409-4077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 FARM GLEN BLVD
Provider Second Line Business Practice Location Address:
PROHEALTH PHYSICIANS
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06032-1981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-284-5200
Provider Business Practice Location Address Fax Number:
860-409-4077
Provider Enumeration Date:
08/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DONAHUE
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
860-284-5207

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 004171659 . This is a "PED MEDICAID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004174439 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004174421 . This is a "FP MEDICAID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004236073 . This is a "PT MEDICAID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: C02126 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".