1154401305 NPI number — TRAVIS B LOMBARDI MPT

Table of content: TRAVIS B LOMBARDI MPT (NPI 1154401305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154401305 NPI number — TRAVIS B LOMBARDI MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOMBARDI
Provider First Name:
TRAVIS
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
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:
1154401305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
772 LONG HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06340-4273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-326-5454
Provider Business Mailing Address Fax Number:
860-326-5502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
772 LONG HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06340-4273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-326-5454
Provider Business Practice Location Address Fax Number:
860-326-5502
Provider Enumeration Date:
10/16/2006

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

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

  • Identifier: 56080005712CT1 . This is a "ANTHEM BCBS PROVIDER NUM" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 7903503 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com