1336205939 NPI number — BROOKFIELD PODIATRY

Table of content: (NPI 1336205939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336205939 NPI number — BROOKFIELD PODIATRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKFIELD PODIATRY
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:
1336205939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
246 FEDERAL RD
Provider Second Line Business Mailing Address:
SUITE C-21
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06804-2647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-740-8637
Provider Business Mailing Address Fax Number:
203-740-8750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
246 FEDERAL RD
Provider Second Line Business Practice Location Address:
SUITE C-21
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06804-2647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-740-8637
Provider Business Practice Location Address Fax Number:
203-740-8750
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CORNELIUS
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
203-740-8637

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  000514 , 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: 030000514CT01 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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