Basic Information
| Provider Information | |||||||||
| NPI: | 1407947526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JANICKI | ||||||||
| FirstName: | MARY BETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 ASYLUM AVE | ||||||||
| Address2: | 2109A | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061051770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607146581 | ||||||||
| FaxNumber: | 8607148311 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061051208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607144595 | ||||||||
| FaxNumber: | 8607148008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 041341 | CT | N | Other Service Providers | Specialist | 207V00000X | 041341 | CT | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VM0101X | 041341 | CT | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 041341 | 01 | CT | LICENSE | OTHER |