1952304263 NPI number — DR. MITCHELL S GARDEN MD

Table of content: DR. MITCHELL S GARDEN MD (NPI 1952304263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952304263 NPI number — DR. MITCHELL S GARDEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDEN
Provider First Name:
MITCHELL
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1952304263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
622 BANTAM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANTAM
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06750-1600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-361-6650
Provider Business Mailing Address Fax Number:
860-361-6654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
622 BANTAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANTAM
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06750-1600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-361-6650
Provider Business Practice Location Address Fax Number:
860-361-6654
Provider Enumeration Date:
05/31/2005

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: 174400000X , with the licence number:  044118 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0117X , with the licence number: 044118 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 044118 , 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: 691155 . This is a "MVP PROVIDER #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P958616 . This is a "OXFORD PROVIDER #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5724688 . This is a "AETNA PPO #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000038402 . This is a "GHI HMO #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01694311 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0599833 . This is a "GHI PPO #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 141796305 . This is a "TAX IDENTIFICATION #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2071599 . This is a "AETNA HMO #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com