1962505453 NPI number — MS. ELISABETH A REILLY APRN

Table of content: MS. ELISABETH A REILLY APRN (NPI 1962505453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962505453 NPI number — MS. ELISABETH A REILLY APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REILLY
Provider First Name:
ELISABETH
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

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:
1962505453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
374 GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06513-3733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-777-7411
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
374 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06513-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-777-7411
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2006

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: 163WP0200X , with the licence number:  E46044 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0222X , with the licence number: 000590 , 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: 400000590CT01 . This is a "BCBS MAP" identifier . This identifiers is of the category "OTHER".
  • Identifier: OV9806 . This is a "PHS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 061470493 . This is a "FIRST CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 061470493 . This is a "UNITED PAYORS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 400000590CT01 . This is a "BC HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 400000590CT01 . This is a "BCBS NATL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 061470493 . This is a "CT HEALTH PIONEER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 400000590CT01 . This is a "BCBS FED PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 061470493 . This is a "CHAMPUS TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 061470493 . This is a "COMMUNITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 400000590CT01 . This is a "BCBS CENT 90" identifier . This identifiers is of the category "OTHER".
  • Identifier: 004184694 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 061470493 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 061470493 . This is a "ONE HEALTH PLANHEALTH CAR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 061470493 . This is a "NE DIRECT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 095000 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 400000590CT01 . This is a "BCBS PREFERRED" identifier . This identifiers is of the category "OTHER".




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