1700898764 NPI number — EAST HARTFORD PEDIATRIC, LLC.

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 1700898764 NPI number — EAST HARTFORD PEDIATRIC, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST HARTFORD PEDIATRIC, 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:
1700898764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 PAUL SPRING RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-676-1135
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
893 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
EAST HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06108-2292
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-289-3047
Provider Business Practice Location Address Fax Number:
860-528-4735
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VENKATESH
Authorized Official First Name:
JAYASHREE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
860-289-3047

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  002155 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 172V00000X , with the licence number: 034733 , 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: 008035516 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001347336 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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