MEDICARE: EUCHARIA MAMBO KENTA-BIBI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	051460	CT

General Provider Information

NPI Number	:	1578717815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EUCHARIA MAMBO KENTA-BIBI MD

Provider Business Mailing Address
First Line	:	1000 SILVER STREET
Second Line	:	CONNECTICUT VALLEY HOSPITAL
City	:	MIDDLETOWN
State	:	CT
Zip	:	06457-7023
Country	:	US
Telephone Number	:	860-262-5154
Fax Number	:	860-262-5122

Provider Business Practice Location Address
First Line	:	1000 SILVER STREET
Second Line	:	CONNECTICUT VALLEY HOSPITAL
City	:	MIDDLETOWN
State	:	CT
Zip	:	06457-7023
Country	:	US
Telephone Number	:	860-262-5154
Fax Number	:	860-262-5122

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2008
Last Update Date	:	11/01/2013

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