1376575324 NPI number — JOHN R. WEST MD INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376575324 NPI number — JOHN R. WEST MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN R. WEST MD INC
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:
6
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:
1376575324
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 WATER ST # 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYSTIC
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06355-2524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-572-9994
Provider Business Mailing Address Fax Number:
860-572-9930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34 WATER ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MYSTIC
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06355-2524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-572-9994
Provider Business Practice Location Address Fax Number:
860-572-9930
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEST
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
860-572-9994

Provider Taxonomy Codes

  • Taxonomy code: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010044204CT01 . 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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