1639111891 NPI number — BETHANY LUCIANI MILLER PA-C

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 1639111891 NPI number — BETHANY LUCIANI MILLER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
BETHANY
Provider Middle Name:
LUCIANI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1639111891
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 NORWICH NEW LONDON TPKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNCASVILLE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06382-2527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-848-1297
Provider Business Mailing Address Fax Number:
860-848-9875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 NORWICH NEW LONDON TPKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNCASVILLE
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06382-2527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-848-1297
Provider Business Practice Location Address Fax Number:
860-848-9875
Provider Enumeration Date:
06/12/2006

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: 207RC0000X , with the licence number:  1434 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 001434 , 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: 290001434CT01 . This is a "ANTHEM/ECCG:06-1049086" identifier . This identifiers is of the category "OTHER".
  • Identifier: 625224 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P3617313 . This is a "OXFORD/ECCD: 06-1616101" identifier . This identifiers is of the category "OTHER".
  • Identifier: P3495612 . This is a "OXFORD/ECCG: 06-1049086" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2V5291 . This is a "HEALTHNET/ECCD:06-1616101" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2V5290 . This is a "HEALTHNET/ECCG:06-1049086" identifier . This identifiers is of the category "OTHER".




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