1275517294 NPI number — ADAM SAMUEL FEDERMAN MD

Table of content: ADAM SAMUEL FEDERMAN MD (NPI 1275517294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275517294 NPI number — ADAM SAMUEL FEDERMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEDERMAN
Provider First Name:
ADAM
Provider Middle Name:
SAMUEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1275517294
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 ENTERPRISE DR
Provider Second Line Business Mailing Address:
STE 220
Provider Business Mailing Address City Name:
SHELTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06484-4694
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-696-3670
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
56 QUARRY ROAD
Provider Second Line Business Practice Location Address:
56 QUARRY ROAD
Provider Business Practice Location Address City Name:
TRUMBULL
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06611-1351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-696-3672
Provider Business Practice Location Address Fax Number:
203-696-6130
Provider Enumeration Date:
12/02/2005

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: 2085R0202X , with the licence number:  046746 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X , with the licence number: 046746 , 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: 02950461 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7953500 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500000187 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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