Healthcare Provider Details

I. General information

NPI: 1407947526
Provider Name (Legal Business Name): MARY BETH JANICKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

1000 ASYLUM AVE 2109A
HARTFORD CT
06105-1770
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-4595
  • Fax: 860-714-8008
Mailing address:
  • Phone: 860-714-6581
  • Fax: 860-714-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number041341
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number041341
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number041341
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: