1598718876 NPI number — C WALLACE ANDRIAS M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598718876 NPI number — C WALLACE ANDRIAS M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

ANDRIAS

Provider First Name:

C

Provider Middle Name:

WALLACE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1598718876

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/21/2022

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

88 PAYER LN

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

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

860-822-3547

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

235 LESTERTOWN RD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

GROTON

Provider Business Practice Location Address State Name:

CT

Provider Business Practice Location Address Postal Code:

06340-2808

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

860-822-3547

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

05/18/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RC0000X , with the licence number:  20133 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 060014262 . This is a "RR MED/ECCG: 06-1049086" identifier . This identifiers is of the category "OTHER".
• Identifier: 500HBC444CT01 . This is a "ANTHEM/HOSP-BASED ECCD" identifier . This identifiers is of the category "OTHER".
• Identifier: 0V9740 . This is a "HEALTHNET/ECCD:06-1616101" identifier . This identifiers is of the category "OTHER".
• Identifier: NLS101 . This is a "OXFORD/ECCG: 06-1049086" identifier . This identifiers is of the category "OTHER".
• Identifier: 001201334 . This is a "BLUECARE FAMILY PLAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 030265 . This is a "HEALTHNET/ECCG:06-1049086" identifier . This identifiers is of the category "OTHER".
• Identifier: 001201334 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
• Identifier: 010020133CT02 . This is a "ANTHEM/ECCG:06-1049086" identifier . This identifiers is of the category "OTHER".
• Identifier: 060064826 . This is a "RR MED/ECCD: 06-1616101" identifier . This identifiers is of the category "OTHER".
• Identifier: P2524339 . This is a "OXFORD/ECCD: 06-1616101" identifier . This identifiers is of the category "OTHER".
• Identifier: 010020133CT06 . This is a "ANTHEM/ECCD:06-1616101" identifier . This identifiers is of the category "OTHER".
• Identifier: 020133 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".