1760408835 NPI number — SOUTH WINDSOR AMBULATORY CARE CTR INC

Table of content: FRANCES ZACZYK (NPI 1649307497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760408835 NPI number — SOUTH WINDSOR AMBULATORY CARE CTR INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH WINDSOR AMBULATORY CARE CTR INC
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:
1760408835
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 510
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH WINDSOR
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06074-0510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-644-3491
Provider Business Mailing Address Fax Number:
860-644-5744

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 TAMARACK AVENUE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
SOUTH WINDSOR
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06074-5539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-644-3491
Provider Business Practice Location Address Fax Number:
860-644-5744
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETRONE
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
860-644-3491

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  024303 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X , with the licence number: 24303 , 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: 010024303CT01 . This is a "BLUE SHIELD OF CT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1751515 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 704554 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 80705 . This is a "GREAT WEST" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 7294618 . This is a "CIGNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0V0438 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 514837 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P3592661 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004263612 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 427750 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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