1639822125 NPI number — WALLINGFORD MEDICAL ASSOCIATES LLC

Table of content: (NPI 1639822125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639822125 NPI number — WALLINGFORD MEDICAL ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLINGFORD MEDICAL ASSOCIATES LLC
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:
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:
1639822125
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 EPISCOPAL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERLIN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06037-1525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-798-2614
Provider Business Mailing Address Fax Number:
860-467-4612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 N MAIN STREET EXT UNIT 1D2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLINGFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06492-2400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-798-2614
Provider Business Practice Location Address Fax Number:
860-467-4612
Provider Enumeration Date:
02/03/2022

Additional Information

Authorized Official

Authorized Official Last Name:
DEE
Authorized Official First Name:
JUANITA
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
860-798-2614

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1669889820 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1609344480 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com