1760567671 NPI number — DR. LAURIE BLUM GRUNEBAUM PH.D.

Table of content: DR. LAURIE BLUM GRUNEBAUM PH.D. (NPI 1760567671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760567671 NPI number — DR. LAURIE BLUM GRUNEBAUM PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRUNEBAUM
Provider First Name:
LAURIE
Provider Middle Name:
BLUM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

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:
1760567671
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
62 TRUMBULL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06510-1022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-776-3667
Provider Business Mailing Address Fax Number:
203-772-1482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
62 TRUMBULL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06510-1022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-776-3667
Provider Business Practice Location Address Fax Number:
203-772-1482
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  001747 , 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: 134296 . This is a "VALUE OPTIONS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060001747CT01 . This is a "ANTHEM BC & BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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