1962680934 NPI number — NEW HAVEN PEDIATRIC & ADOLESCENT MEDICAL SERV

Table of content: (NPI 1962680934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962680934 NPI number — NEW HAVEN PEDIATRIC & ADOLESCENT MEDICAL SERV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW HAVEN PEDIATRIC & ADOLESCENT MEDICAL SERV
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:
TAMIKO V JACKSON MD
Provider Other Organization Name Type Code:
3
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:
1962680934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1423 CHAPEL ST
Provider Second Line Business Mailing Address:
UNIT 2B
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-752-0706
Provider Business Mailing Address Fax Number:
203-772-0387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1423 CHAPEL ST
Provider Second Line Business Practice Location Address:
UNIT 2B
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-752-0706
Provider Business Practice Location Address Fax Number:
203-772-0387
Provider Enumeration Date:
02/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
ANGEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
203-906-3854

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0136872 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0200X , with the licence number: 0002815 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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