1770557712 NPI number — EASTERN CONNECTICUT MEDICAL PROFESSIONALS FOUNDATION INC

Table of content: (NPI 1770557712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770557712 NPI number — EASTERN CONNECTICUT MEDICAL PROFESSIONALS FOUNDATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN CONNECTICUT MEDICAL PROFESSIONALS FOUNDATION INC
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:
EASTERN CT MEDICAL PROFESSIONALS
Provider Other Organization Name Type Code:
3
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:
1770557712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
71 HAYNES ST
Provider Second Line Business Mailing Address:
MILLER BLDG, FLOOR G
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06040-4131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-533-2981
Provider Business Mailing Address Fax Number:
860-533-2975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
71 HAYNES ST
Provider Second Line Business Practice Location Address:
MILLER BLDG, FLOOR G
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06040-4131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-533-2981
Provider Business Practice Location Address Fax Number:
860-533-2975
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KARL
Authorized Official First Name:
PETER
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
860-646-1222

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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: 207RE0101X ; 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: 207VX0201X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X ; 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" .

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

  • Identifier: 004212750 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004271285 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004268571 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004271300 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01003917CT05 . This is a "ANTHEM ID - ALI HEMACHA, MD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004268620 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004181351 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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