1578624474 NPI number — DR. MIRIAM J. SIVKIN M.D.

Table of content: (NPI 1245398130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578624474 NPI number — DR. MIRIAM J. SIVKIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIVKIN
Provider First Name:
MIRIAM
Provider Middle Name:
J.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1578624474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
247 BROAD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06460-3267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-783-0543
Provider Business Mailing Address Fax Number:
203-874-5728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
247 BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06460-3267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-783-0543
Provider Business Practice Location Address Fax Number:
203-874-5728
Provider Enumeration Date:
12/13/2006

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: 207V00000X , with the licence number:  029814 , 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: 127938 . This is a "PREFERRED ONE WELLCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 161664854 . This is a "TAX I.D. NO" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: ZP116 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 010029814CT01 . This is a "ANTHEM I.D. NO." identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 2V3325 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004237112 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 029814 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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