1740314061 NPI number — JOHNSON OCCUPATIONAL MEDICINE CENTER

Table of content: (NPI 1740314061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740314061 NPI number — JOHNSON OCCUPATIONAL MEDICINE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHNSON OCCUPATIONAL MEDICINE CENTER
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:
1740314061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1153
Provider Second Line Business Mailing Address:
3 WEYMOUTH ROAD
Provider Business Mailing Address City Name:
ENFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06083-1153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-763-7668
Provider Business Mailing Address Fax Number:
860-763-7676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 WEYMOUTH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06083-1153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-763-7668
Provider Business Practice Location Address Fax Number:
860-763-7676
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ERDIL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
860-763-7668

Provider Taxonomy Codes

  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010245 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P3201009 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 010023596CT11 . This is a "ANTHEM" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V4744 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 3015101 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: CU7369 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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