Basic Information
| Provider Information | |||||||||
| NPI: | 1205907474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEPAGE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 377 N MAIN ST APT 2 | ||||||||
| Address2: | |||||||||
| City: | NAUGATUCK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067703228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036879384 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 900 STRAITS TPKE | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067622800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035775325 | ||||||||
| FaxNumber: | 2035775329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 006972 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 080006972CT06 | 01 | CT | BCBS ID # | OTHER |