1962538348 NPI number — STATE OF CT. - OFFICE OF THE COMPTROLLER

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 1962538348 NPI number — STATE OF CT. - OFFICE OF THE COMPTROLLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF CT. - OFFICE OF THE COMPTROLLER
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:
STS COTTAGE 30
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:
1962538348
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 872
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06488-0901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-586-2000
Provider Business Mailing Address Fax Number:
203-586-2700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1461 BRITAIN RD S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06488-1139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-586-2000
Provider Business Practice Location Address Fax Number:
203-586-2700
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SECCHIAROLI
Authorized Official First Name:
CRESCENTINO
Authorized Official Middle Name:
L
Authorized Official Title or Position:
FISCAL ADMINISTRATOR
Authorized Official Telephone Number:
860-418-8712

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 006782321 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: C00793 . This is a "MEDICARE ID - TYPE UNSPECIFIED" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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