1730288697 NPI number — CT COMPREHENSIVE NEUROLOGIC MANAGEMENT, LLC

Table of content: (NPI 1730288697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730288697 NPI number — CT COMPREHENSIVE NEUROLOGIC MANAGEMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CT COMPREHENSIVE NEUROLOGIC MANAGEMENT, 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:
1730288697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06473-2349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-234-1993
Provider Business Mailing Address Fax Number:
203-234-7147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06473-2349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-234-1993
Provider Business Practice Location Address Fax Number:
203-234-7147
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MEDNICK
Authorized Official First Name:
ROSALIE
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
203-234-1993

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  037501 , 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: 0Q3637 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 3223587 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P2491200 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 317063 . This is a "WELLCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 9794136003 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 010037501CT02 . This is a "ANTHEM" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 772945 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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