1356322358 NPI number — ELIZABETH MAE ROESSLER PA

Table of content: ELIZABETH MAE ROESSLER PA (NPI 1356322358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356322358 NPI number — ELIZABETH MAE ROESSLER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROESSLER
Provider First Name:
ELIZABETH
Provider Middle Name:
MAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1356322358
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 208237
Provider Second Line Business Mailing Address:
55 LOCK ST
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
05511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-432-0076
Provider Business Mailing Address Fax Number:
203-432-7289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
374 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06513-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-777-7411
Provider Business Practice Location Address Fax Number:
203-401-2042
Provider Enumeration Date:
11/08/2005

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: 363A00000X , with the licence number:  000673 , 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: 290000673CT03 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 970025160 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P2685637 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0V8014 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 673000I420 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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