1336192608 NPI number — EASTERN CONN. CARDIOLOGY GROUP

Table of content: (NPI 1336192608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336192608 NPI number — EASTERN CONN. CARDIOLOGY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN CONN. CARDIOLOGY GROUP
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:
1336192608
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
196 PARKWAY S
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
WATERFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06385-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-443-4383
Provider Business Mailing Address Fax Number:
860-443-3980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
196 PARKWAY S
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06385-1234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-443-4383
Provider Business Practice Location Address Fax Number:
860-443-3980
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EHRLICH
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
860-443-4383

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004047577 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: CJ0983 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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