1164403465 NPI number — CARLA R SANDBERG MD

Table of content: CARLA R SANDBERG MD (NPI 1164403465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164403465 NPI number — CARLA R SANDBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANDBERG
Provider First Name:
CARLA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1164403465
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 FOUNDERS PLZ
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
EAST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06108-3212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-289-3375
Provider Business Mailing Address Fax Number:
860-783-5733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 SEYMOUR ST
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06106-5501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-289-3375
Provider Business Practice Location Address Fax Number:
860-783-5733
Provider Enumeration Date:
11/14/2005

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: 2085R0202X , with the licence number:  029919 , 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: 1299199 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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