1336196773 NPI number — MARATHON HEALTHCARE OF TORRINGTON

Table of content: (NPI 1336196773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336196773 NPI number — MARATHON HEALTHCARE OF TORRINGTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARATHON HEALTHCARE OF TORRINGTON
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:
1336196773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 FERN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TORRINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06790-3807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-482-7668
Provider Business Mailing Address Fax Number:
860-482-3963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
99 E RIVER DR
Provider Second Line Business Practice Location Address:
RIVERVIEW SQUARE 8THFLOOR
Provider Business Practice Location Address City Name:
EAST HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06108-3288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-520-0007
Provider Business Practice Location Address Fax Number:
860-528-5711
Provider Enumeration Date:
05/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CZERNIEWSKI
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
860-290-7514

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2301 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 900009621 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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