Healthcare Provider Details

I. General information

NPI: 1194412700
Provider Name (Legal Business Name): ANDREI LIEDERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 HARTFORD RD
MANCHESTER CT
06040-5921
US

IV. Provider business mailing address

71 HAYNES ST
MANCHESTER CT
06040-4188
US

V. Phone/Fax

Practice location:
  • Phone: 860-533-4679
  • Fax:
Mailing address:
  • Phone: 860-533-4679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number34.018490
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: