1982914354 NPI number — PETER T. KRENICKY MD PC

Table of content: (NPI 1982914354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982914354 NPI number — PETER T. KRENICKY MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETER T. KRENICKY MD 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:
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:
1982914354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
477 CONNECTICUT BLVD.
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
EAST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-528-9645
Provider Business Mailing Address Fax Number:
860-528-6366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
477 CONNECTICUT BLVD.
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
EAST HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-528-9645
Provider Business Practice Location Address Fax Number:
860-528-6366
Provider Enumeration Date:
10/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KRENICKY
Authorized Official First Name:
PETER
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PRINCIPLE
Authorized Official Telephone Number:
860-528-9645

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  013523 , 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: 001135235 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010013529CT . This is a "BCBS OF CT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 298521 . This is a "WELLCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 013523 . This is a "CONNETICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 117584 . This is a "EYEMED" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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