1154308229 NPI number — EAST GRANBY FAMILY PRACTICE LLC

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 1154308229 NPI number — EAST GRANBY FAMILY PRACTICE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST GRANBY FAMILY PRACTICE LLC
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:
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:
1154308229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13 CHURCH RD
Provider Second Line Business Mailing Address:
PO BOX 518
Provider Business Mailing Address City Name:
EAST GRANBY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06026-0518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-653-4526
Provider Business Mailing Address Fax Number:
860-653-5209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13 CHURCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST GRANBY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06026-0518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-653-4526
Provider Business Practice Location Address Fax Number:
860-653-5209
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DIETRICH
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PARTNER MD
Authorized Official Telephone Number:
860-653-4526

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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