Basic Information
| Provider Information | |||||||||
| NPI: | 1316943285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEDDIS | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LORD | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | G. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 KENSINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060513916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602246282 | ||||||||
| FaxNumber: | 8608264959 | ||||||||
| Practice Location | |||||||||
| Address1: | 184 EAST ST | ||||||||
| Address2: | |||||||||
| City: | PLAINVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060622913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607471132 | ||||||||
| FaxNumber: | 8607472028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 031048 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 060040 | 01 | CT | HEALTH NET ID | OTHER | 1255448155 | 01 | CT | GHMC NPI ID | OTHER | 476805 | 01 | CT | AETNA REF ID | OTHER | 010031048CT03 | 01 | CT | BCBS NBCFP PLAINVILLE ID | OTHER | 010031048CT04 | 01 | CT | BCBSN BCFP NB ID | OTHER | 01031048 | 01 | CT | CIGNA ID | OTHER | 912429 | 01 | CT | HEALTH NET REF ID | OTHER | 71668401 | 01 | CT | CONNECTICARE ID | OTHER | P369863 | 01 | CT | OXFORD ID | OTHER | 126638 | 01 | CT | WELLCARE MEDICARE | OTHER |