1700864097 NPI number — MEDICAL SPECIALISTS OF FAIRFIELD, LLC

Table of content: (NPI 1700864097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700864097 NPI number — MEDICAL SPECIALISTS OF FAIRFIELD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL SPECIALISTS OF FAIRFIELD, 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:
SWIM HEMATOLOGY ONCOLOGY
Provider Other Organization Name Type Code:
3
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:
1700864097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 POST RD
Provider Second Line Business Mailing Address:
SOUTH LOBBY
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06824-6232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-255-4545
Provider Business Mailing Address Fax Number:
203-254-1191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 MAIN ST
Provider Second Line Business Practice Location Address:
3RD FLR
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06606-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-382-2475
Provider Business Practice Location Address Fax Number:
203-382-2488
Provider Enumeration Date:
01/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REZNIKOFF
Authorized Official First Name:
GLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
203-255-4545

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 010013862CT01 . This is a "BCBS CT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004082666 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104363800 . This is a "DEPT OF LABOR" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: S2G58 . This is a "BCBS NY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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