1851643654 NPI number — VALLEY VASCULAR ASSOCIATES LLC

Table of content: (NPI 1851643654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851643654 NPI number — VALLEY VASCULAR ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLEY VASCULAR ASSOCIATES LLC
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:
1851643654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
91 EAST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWALK
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06851-5020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-855-9806
Provider Business Mailing Address Fax Number:
203-855-1135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
91 EAST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORWALK
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06851-5020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-855-9806
Provider Business Practice Location Address Fax Number:
203-855-1135
Provider Enumeration Date:
10/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SHIN
Authorized Official First Name:
CHUNG
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MANAGING OFFICER
Authorized Official Telephone Number:
203-855-9806

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  037720 , 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: 178311 . This is a "WELLCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P2061278 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001377200 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2322912 . This is a "AETNA/US HEALTHCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 770002444 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 010037720CT02 . This is a "ANTHEM - DERBY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 010037720CT03 . This is a "ANTHEM -NORWALK" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 010037720CT04 . This is a "ANTHEM - BPT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 037720 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 3324246-004 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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