1508981713 NPI number — EAR NOSE & THROAT SPECIALISTS OF CENTRAL CONNECTICUT P.C.

Table of content: (NPI 1508981713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508981713 NPI number — EAR NOSE & THROAT SPECIALISTS OF CENTRAL CONNECTICUT P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAR NOSE & THROAT SPECIALISTS OF CENTRAL CONNECTICUT P.C.
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:
1508981713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
233 MAIN ST
Provider Second Line Business Mailing Address:
5TH FLOOR
Provider Business Mailing Address City Name:
NEW BRITAIN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06051-4204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-225-7761
Provider Business Mailing Address Fax Number:
860-225-6657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
233 MAIN ST
Provider Second Line Business Practice Location Address:
5TH FLOOR
Provider Business Practice Location Address City Name:
NEW BRITAIN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06051-4204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-225-7761
Provider Business Practice Location Address Fax Number:
860-225-6657
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRYBOSKI
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
ANDRE
Authorized Official Title or Position:
OTOLARYNGOLOGIST
Authorized Official Telephone Number:
860-225-7761

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  12647 , 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: 010012647CT01 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 04002630 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004190196 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: HAS700 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004105294 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010012647CT01 . This is a "BLUE CARE FAMILY PLAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: OR4199 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 073071 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 517950 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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