1750389524 NPI number — DR. PAMELA L MANTHOUS M.D.

Table of content: DR. PAMELA L MANTHOUS M.D. (NPI 1750389524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750389524 NPI number — DR. PAMELA L MANTHOUS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANTHOUS
Provider First Name:
PAMELA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BALLING
Provider Other First Name:
PAMELA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750389524
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 KENSINGTON AVE
Provider Second Line Business Mailing Address:
GROVE HILL MEDICAL CENTER
Provider Business Mailing Address City Name:
NEW BRITAIN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06051-3916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-666-5111
Provider Business Mailing Address Fax Number:
860-666-5153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 CEDAR ST
Provider Second Line Business Practice Location Address:
GROVE HILL MEDICAL CENTER
Provider Business Practice Location Address City Name:
NEWINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06111-2647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-666-5111
Provider Business Practice Location Address Fax Number:
860-666-5153
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  032643 , 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: 3264301 . This is a "CONNECTICARE PROV ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 368783 . This is a "WELLCARE MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 912607 . This is a "HEALTH NET REF ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 010032643CT . This is a "BCBS N BCFP PROV ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 01032643 . This is a "CIGNA PROV ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060074 . This is a "HEALTH NET PROV ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004196095 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1255448155 . This is a "GHMC GRP NPI PROV ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 500222 . This is a "AETNA PROV ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P369849 . This is a "OXFORD PROV ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001326439 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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