1104870773 NPI number — MARK A ROTELLA PT

Table of content: MARK A ROTELLA PT (NPI 1104870773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104870773 NPI number — MARK A ROTELLA PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTELLA
Provider First Name:
MARK
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1104870773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 NEWTOWN RD # A
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
DANBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06810-4194
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-739-0765
Provider Business Mailing Address Fax Number:
203-739-0792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 WATERMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02914-1314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-434-1773
Provider Business Practice Location Address Fax Number:
401-435-0500
Provider Enumeration Date:
05/19/2006

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: 225100000X , with the licence number:  02006 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 007027 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1114979226 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1114979226 . This is a "ANTHEM" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1114979226 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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