Basic Information
| Provider Information | |||||||||
| NPI: | 1942264288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RADEBOLD | ||||||||
| FirstName: | ANDREA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 960 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRANFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064053730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034886358 | ||||||||
| FaxNumber: | 2034815327 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRANFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064053730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034886358 | ||||||||
| FaxNumber: | 2034815327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 042296 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010042296CT01 | 01 | ANTHEM BCBS | OTHER | P00140199 | 01 | RAILROAD MEDICARE | OTHER | 001422964 | 05 | CT | MEDICAID | 042296 | 01 | CONNECTICARE | OTHER | 3680171 | 01 | AETNA | OTHER | 0Q2728 | 01 | HEALTHNET | OTHER | P3340613 | 01 | OXFORD | OTHER |