1639164775 NPI number — DR. MARK R VERSLAND M.D.

Table of content: DR. MARK R VERSLAND M.D. (NPI 1639164775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639164775 NPI number — DR. MARK R VERSLAND M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VERSLAND
Provider First Name:
MARK
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1639164775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2139 SILAS DEANE HIGHWAY
Provider Second Line Business Mailing Address:
CONNECTICUT GI, PC
Provider Business Mailing Address City Name:
ROCKY HILL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06067-1327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-257-4131
Provider Business Mailing Address Fax Number:
860-257-4519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 LIBERTY SQUARE FLOOR 2
Provider Second Line Business Practice Location Address:
CONNECTICUT GI, PC
Provider Business Practice Location Address City Name:
NEW BRITAIN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06051-2637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-229-9688
Provider Business Practice Location Address Fax Number:
860-229-5498
Provider Enumeration Date:
09/14/2005

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: 207RG0100X , with the licence number:  028335 , 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: 0925918002 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 744458 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0076300 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001283358 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: HAS486 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 010028335CT01 . This is a "ANTHEM BC" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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