1790987709 NPI number — DR. LEIGH ROWAN-KELLY MD FASAM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790987709 NPI number — DR. LEIGH ROWAN-KELLY MD FASAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROWAN-KELLY
Provider First Name:
LEIGH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD FASAM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROWAN-KELLY
Provider Other First Name:
MICHAEL
Provider Other Middle Name:
CHARLES LEIGH
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD FASAM
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790987709
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 SUMMIT CREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH GLASTONBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06073-2944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-416-6168
Provider Business Mailing Address Fax Number:
860-430-2672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 ISLAND DOCK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HADDAM
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06438-1036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-416-6168
Provider Business Practice Location Address Fax Number:
860-430-2672
Provider Enumeration Date:
06/01/2007

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: 207QA0401X , with the licence number:  68097 , 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: 390200000X . This is a "TAXONOMY" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2026 www.npivalidator.com