1568458644 NPI number — AMY T MOORADIAN DPT

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 1568458644 NPI number — AMY T MOORADIAN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORADIAN
Provider First Name:
AMY
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEDEIROS
Provider Other First Name:
AMY
Provider Other Middle Name:
T
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568458644
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 BEACON HILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06385-4108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-910-9571
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1666 ROUTE 12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALES FERRY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06335-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-941-9126
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  009106 , 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: 050513332 . This is a "GREATWEST" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: P00322419 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 050513332 . This is a "CHAMPUS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 103959900 . This is a "USDE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 26848 . This is a "BLUE CROSS BLUE SHIELD RI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 5669517 . This is a "COVENTRY HEALTH FIRST HEA" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9378895 . This is a "PHCS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 268480 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 050513332 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 411015 . This is a "BLUE CHIP RI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 779850 . This is a "AETNA" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9378895 . This is a "GUARDIAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 050513332 . This is a "CCN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 103959900 . This is a "DLWC" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: AA1566 . This is a "PILGRIM" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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