Basic Information
| Provider Information | |||||||||
| NPI: | 1730163502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORMICA | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | NICHOLAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9805 | ||||||||
| Address2: | 300 GEORGE ST 6TH FLOOR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065360805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037857998 | ||||||||
| FaxNumber: | 2037856414 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 HOWARD AVE | ||||||||
| Address2: | YALE PHYSICIANS BUILDING | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037852140 | ||||||||
| FaxNumber: | 2037856414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 03/22/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036848 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 208M00000X | 036848 | CT | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 001368481 | 05 | CT | MEDICAID |