=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578717815
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EUCHARIA MAMBO KENTA-BIBI MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2008
-----------------------------------------------------
Last Update Date | 11/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 SILVER STREET CONNECTICUT VALLEY HOSPITAL
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-7023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-262-5154
-----------------------------------------------------
Fax | 860-262-5122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 SILVER STREET CONNECTICUT VALLEY HOSPITAL
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-7023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-262-5154
-----------------------------------------------------
Fax | 860-262-5122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 051460
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------