1821135476 NPI number — MRS. LISA MICHELE GULINO LISA GULINO

Table of content: MRS. LISA MICHELE GULINO LISA GULINO (NPI 1821135476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821135476 NPI number — MRS. LISA MICHELE GULINO LISA GULINO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GULINO
Provider First Name:
LISA
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LISA GULINO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAURIA
Provider Other First Name:
LISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LISA GULINO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821135476
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
68 SOUTH SERVICE ROAD
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
MELVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-945-3000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 GREAT MEADOW RD
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
WETHERSFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-563-0700
Provider Business Practice Location Address Fax Number:
860-563-0741
Provider Enumeration Date:
01/31/2007

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: 367500000X , with the licence number:  003565 , 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: 121499200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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