Basic Information
| Provider Information | |||||||||
| NPI: | 1154305985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RACKOW | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | WENDY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 SARGENT DR | ||||||||
| Address2: | YALE REPRO. ENDOCRINOLOGY | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065116100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037854708 | ||||||||
| FaxNumber: | 2037645619 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 SARGENT DR | ||||||||
| Address2: | YALE REPRO. ENDOCRINOLOGY | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065116100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037854708 | ||||||||
| FaxNumber: | 2037645619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 03/14/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 042218 | CT | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 001422188 | 05 | CT | MEDICAID |