1780887950 NPI number — MANDELL & BLAU, MD'S PC

Table of content: (NPI 1780887950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780887950 NPI number — MANDELL & BLAU, MD'S PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANDELL & BLAU, MD'S PC
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:
6
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:
1780887950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLASTONBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06033-0230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-657-2242
Provider Business Mailing Address Fax Number:
860-657-2264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 MAIN ST
Provider Second Line Business Practice Location Address:
METRO SQUARE
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06457-3437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-633-8806
Provider Business Practice Location Address Fax Number:
860-346-7400
Provider Enumeration Date:
06/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BARKOFF
Authorized Official First Name:
NEAL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
860-633-8806

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A369503 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: CJ5750 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V0862 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060857 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 15MRI0016CT05 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 222094 . This is a "WELLCARE/PREFERRED ONE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4000931 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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