1710941406 NPI number — PAIN MANAGEMENT CENTER OF NEW ENGLAND

Table of content: (NPI 1710941406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710941406 NPI number — PAIN MANAGEMENT CENTER OF NEW ENGLAND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT CENTER OF NEW ENGLAND
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:
1710941406
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2440 WHITNEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMDEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06518-3222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-248-1134
Provider Business Mailing Address Fax Number:
203-288-6132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2440 WHITNEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06518-3222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-248-1134
Provider Business Practice Location Address Fax Number:
203-288-6132
Provider Enumeration Date:
04/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WANG
Authorized Official First Name:
JOSEF
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
203-248-1134

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  026896 , 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: 1497217 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 010026896CT02 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: OV6331 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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