Basic Information
| Provider Information | |||||||||
| NPI: | 1942423710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRAVITZ | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | BARRY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS, ATC, LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 466 S ELM ST | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064924817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608057259 | ||||||||
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| Practice Location | |||||||||
| Address1: | 230 GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034985980 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2255A2300X | 000118 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | PROVIDER CODE 22 | 01 | CT | RESPIRATORY, REHABILITATI | OTHER |