Basic Information
Provider Information | |||||||||
NPI: | 1447325535 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANGIELLO-SMITH | ||||||||
FirstName: | MAURA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1275 SUMMER ST | ||||||||
Address2: | SUITE 301 | ||||||||
City: | STAMFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 069055359 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033244100 | ||||||||
FaxNumber: | 2039691271 | ||||||||
Practice Location | |||||||||
Address1: | 1275 SUMMER ST | ||||||||
Address2: | SUITE 301 | ||||||||
City: | STAMFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 069055359 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033244100 | ||||||||
FaxNumber: | 2039691271 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2006 | ||||||||
LastUpdateDate: | 11/16/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 042324 | CT | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 042324 | 01 | CT | CONNECTICARE | OTHER | 3538087 | 01 | CT | AETNA | OTHER | P3254682 | 01 | CT | OXFORD | OTHER | 06-0873781 | 01 | CT | GREAT WEST | OTHER | 11213145 | 01 | CT | CAQH | OTHER | 06-0873781 | 01 | CT | NORTHEAST HEALTHCARE ALLI | OTHER | 2V4896 | 01 | CT | HEALTHNET | OTHER | 010042324CT01 | 01 | CT | BLUE CROSS-STAMFORD | OTHER | 06-0873781 | 01 | CT | HUMANA CHOICECARE | OTHER | 06-0873781 | 01 | CT | UNITED | OTHER | 001423243 | 05 | CT |   | MEDICAID | 010042324CT02 | 01 | CT | BLUE CROSS-DARIEN | OTHER | 06-0873781 | 01 | CT | CIGNA | OTHER | 06-0873781 | 01 | CT | PHCS | OTHER |