Basic Information
| Provider Information | |||||||||
| NPI: | 1609888668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TENICKI | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 SHELBURNE RD | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069023628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032767298 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 SHELBURNE RD | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069023628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032767298 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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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 | 207R00000X | 041551 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | TIN | 01 | GREAT WEST | OTHER | TIN | 01 | CHN SOLUTIONS | OTHER | P3044450 | 01 | CT | OXFORD HEALTH PLAN | OTHER | TIN | 01 | FOCUS | OTHER | TIN | 01 | FIRST HEALTH/ CCN | OTHER | TIN | 01 | NORTHEAST HEALTH DIRECT | OTHER | 3308535 | 01 | CT | AETNA - HMO | OTHER | 473P62 | 01 | CT | EMPIRE BC/BS | OTHER | 9441583 | 01 | CT | CIGNA | OTHER | 010041551CT01 | 01 | CT | ANTHEM BC/BS | OTHER | 041551 | 01 | CT | CONNECTICARE | OTHER | 2V4593 | 01 | CT | HEALTH NET | OTHER | P00074279 | 01 | CT | RAILROAD MEDICARE | OTHER | TIN | 01 | PRIVATE HEALTHCARE SYSTE | OTHER | TIN | 01 | POMCO | OTHER | TIN | 01 | UNITED HEALTHCARE | OTHER | 7267461 | 01 | CT | AETNA - PPO | OTHER |