Basic Information
Provider Information | |||||||||
NPI: | 1194712596 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASSOCIATED NEUROLOGISTS OF SOUTHERN CONNECTICUT, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 75 KINGS HIGHWAY CUTOFF | ||||||||
Address2: | 5TH FLOOR | ||||||||
City: | FAIRFIELD | ||||||||
State: | CT | ||||||||
PostalCode: | 068245340 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033331133 | ||||||||
FaxNumber: | 2033333937 | ||||||||
Practice Location | |||||||||
Address1: | 75 KINGS HIGHWAY CUTOFF | ||||||||
Address2: | 5TH FLOOR | ||||||||
City: | FAIRFIELD | ||||||||
State: | CT | ||||||||
PostalCode: | 068245340 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033331133 | ||||||||
FaxNumber: | 2033333937 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2005 | ||||||||
LastUpdateDate: | 08/01/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SIEGEL | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: | COLEMAN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2033331133 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X |   | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 103G00000X |   | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   |
ID Information
ID | Type | State | Issuer | Description | 4081999 | 05 | CT |   | MEDICAID |