Basic Information
Provider Information | |||||||||
NPI: | 1134145808 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIELING | ||||||||
FirstName: | BETH | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 56 FRANKLIN ST | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | WATERBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 067061253 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037098882 | ||||||||
FaxNumber: | 2037098689 | ||||||||
Practice Location | |||||||||
Address1: | 33 BULLET HILL RD. | ||||||||
Address2: | SUITE 214 | ||||||||
City: | SOUTHBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 064884699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2032671563 | ||||||||
FaxNumber: | 2032671583 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2006 | ||||||||
LastUpdateDate: | 11/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 043694 | CT | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 001436949 | 05 | CT |   | MEDICAID |