Basic Information
Provider Information | |||||||||
NPI: | 1124122650 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CRISCUOLO BECK | ||||||||
FirstName: | AIMEE | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CRISCUOLO | ||||||||
OtherFirstName: | AIMEE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 420 SAYBROOK RD | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | CT | ||||||||
PostalCode: | 064574747 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606262010 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 481 GOLD STAR HWY STE 100 | ||||||||
Address2: |   | ||||||||
City: | GROTON | ||||||||
State: | CT | ||||||||
PostalCode: | 063406702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8604468858 | ||||||||
FaxNumber: | 8604052140 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2006 | ||||||||
LastUpdateDate: | 11/04/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 000925 | CT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 000925 | 01 | CT | CONNECTICARE | OTHER | 290000925CT01 | 01 | CT | ANTHEM BC/BS | OTHER |