1760856181 NPI number — KMG THERAPY AND CONSULTING LLC

Table of content: (NPI 1760856181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760856181 NPI number — KMG THERAPY AND CONSULTING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KMG THERAPY AND CONSULTING 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:
1760856181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1075 E LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKDALE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06370-1818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-917-1779
Provider Business Mailing Address Fax Number:
860-447-8122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
481 GOLD STAR HWY
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06340-6702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-917-1779
Provider Business Practice Location Address Fax Number:
860-447-8122
Provider Enumeration Date:
11/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GALLAGHER
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
860-917-1779

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  8823 , 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: 0006568 . This is a "VALUEOPTIONS CT BHP" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 008056500 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: D300184136 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 13515495 . This is a "COUNCIL FOR AFFORDABLE QUALITY HEALTH (CAQH)" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 544181 . This is a "MANAGED HEALTH NETWORK (MHN)" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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