1609092121 NPI number — INTERNAL MEDICINE AND INFECTIOUS DISEASE ASSOCIATED P.C.

Table of content: (NPI 1609092121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609092121 NPI number — INTERNAL MEDICINE AND INFECTIOUS DISEASE ASSOCIATED P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE AND INFECTIOUS DISEASE ASSOCIATED 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:
1609092121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3241 MAIN STREET
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
STRATFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-383-4466
Provider Business Mailing Address Fax Number:
203-383-4499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3241 MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
STRATFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-383-4466
Provider Business Practice Location Address Fax Number:
203-383-4499
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SAUL
Authorized Official First Name:
ZANE
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-383-4466

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4223872 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 88817 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: C02852 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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