{
"NPI": [
{
"NPI": "1437152360",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "ARCHER-GOODE",
"FirstName": "CORLIS",
"MiddleName": "L.",
"NamePrefix": "DR.",
"Credential": "M.D.",
"OtherLastName": "ARCHER",
"OtherFirstName": "CORLIS",
"OtherMiddleName": "L",
"OtherNamePrefix": "DR.",
"OtherCredential": "M.D.",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-826-4453",
"MailingAddressFaxNumber": "860-826-6219",
"FirstLinePracticeLocationAddress": "1 LAKE ST",
"SecondLinePracticeLocationAddress": "BLDG B2ND",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06052-1396",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-826-4453",
"PracticeLocationAddressFaxNumber": "860-826-6219",
"EnumerationDate": "05/24/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "F",
"Gender": "Female",
"TaxonomyCode1": "208800000X",
"Taxonomy1": "Urology Physician",
"LicenseNumber1": "038810",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "1255448155",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "GHMC GROUP NPI",
"OtherIdentifier2": "O2096535",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "OXFORD",
"OtherIdentifier3": "01038810",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "CIGNA",
"OtherIdentifier4": "00138810CT01",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "BCBS & BCFP",
"OtherIdentifier5": "0V7374",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "HEALTH NET",
"OtherIdentifier6": "2355107",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "AETNA",
"PrimaryTaxonomyCode": "208800000X",
"PrimaryTaxonomy": "Urology Physician"
},
{
"NPI": "1164425070",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "BELNIAK",
"FirstName": "ROBERT",
"MiddleName": "M",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-832-4666",
"MailingAddressFaxNumber": "860-348-4931",
"FirstLinePracticeLocationAddress": "73 CEDAR ST",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06052-1390",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-832-4666",
"PracticeLocationAddressFaxNumber": "860-348-4931",
"EnumerationDate": "05/24/2005",
"LastUpdateDate": "06/11/2010",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207X00000X",
"Taxonomy1": "Orthopaedic Surgery Physician",
"LicenseNumber1": "27460",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "N",
"TaxonomyCode2": "207XX0005X",
"Taxonomy2": "Sports Medicine (Orthopaedic Surgery) Physician",
"LicenseNumber2": "27460",
"LicenseNumberStateCode2": "CT",
"PrimaryTaxonomySwitch2": "Y",
"OtherIdentifier1": "010027460CT01",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "BCBS & BCFP",
"OtherIdentifier2": "060044",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "HEALTH NET",
"OtherIdentifier3": "1255448155",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "GHMC GROUP NPI ID",
"OtherIdentifier4": "P369851",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "OXFORD",
"OtherIdentifier5": "02746001",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "CONNECTICARE",
"OtherIdentifier6": "481697",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "AETNA",
"OtherIdentifier7": "01227460",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "CIGNA",
"OtherIdentifier8": "200015189",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "RAIL ROAD MEDICARE",
"OtherIdentifier9": "004214467",
"OtherIdentifierType9": "MEDICAID",
"OtherIdentifierState9": "CT",
"PrimaryTaxonomyCode": "207XX0005X",
"PrimaryTaxonomy": "Sports Medicine (Orthopaedic Surgery) Physician"
},
{
"NPI": "1124021183",
"NPIDeactivationDate": "05/01/2025"
},
{
"NPI": "1174525497",
"NPIDeactivationDate": "08/11/2026"
},
{
"NPI": "1497757702",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "CURRAO",
"FirstName": "WILLIAM",
"MiddleName": "J",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-224-6282",
"MailingAddressFaxNumber": "860-826-4959",
"FirstLinePracticeLocationAddress": "300 KENSINGTON AVE",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06051-3916",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-224-6282",
"PracticeLocationAddressFaxNumber": "860-826-4959",
"EnumerationDate": "06/01/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "208000000X",
"Taxonomy1": "Pediatrics Physician",
"LicenseNumber1": "027411",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "060076",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "HEALTH NET",
"OtherIdentifier2": "1255448155",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "GHMC GRP NPI ID",
"OtherIdentifier3": "P369834",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "OXFORD",
"OtherIdentifier4": "01027411",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "CIGNA",
"OtherIdentifier5": "476828",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "AETNA",
"OtherIdentifier6": "2025501",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "CONNECTICARE",
"OtherIdentifier7": "010027411CT01",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "BCBS & BCFP",
"PrimaryTaxonomyCode": "208000000X",
"PrimaryTaxonomy": "Pediatrics Physician"
},
{
"NPI": "1477555787",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "D'AMATO",
"FirstName": "RAYMOND",
"MiddleName": "L",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-224-6200",
"MailingAddressFaxNumber": "860-224-6260",
"FirstLinePracticeLocationAddress": "136 BERLIN RD",
"SecondLinePracticeLocationAddress": "SUITE 102",
"PracticeLocationAddressCityName": "CROMWELL",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06416-2627",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-635-2810",
"PracticeLocationAddressFaxNumber": "860-632-2352",
"EnumerationDate": "06/01/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207R00000X",
"Taxonomy1": "Internal Medicine Physician",
"LicenseNumber1": "017716",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "01217716",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "CIGNA ID",
"OtherIdentifier2": "060916784009",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "TRICARE HNFS ID",
"OtherIdentifier3": "P369835",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "OXFORD PROVIDER ID",
"OtherIdentifier4": "060078",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "HEALTH NET ID",
"OtherIdentifier5": "010017716CT02",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "BCBS COMMERCIAL N BCFP ID",
"OtherIdentifier6": "050843",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "CONNECTICARE ID",
"OtherIdentifier7": "1255448155",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "GHMC GRP NPI ID",
"OtherIdentifier8": "501435",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "AETNA PROVIDER ID",
"OtherIdentifier9": "912611",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "HEALTH NET REFERRAL ID",
"PrimaryTaxonomyCode": "207R00000X",
"PrimaryTaxonomy": "Internal Medicine Physician"
},
{
"NPI": "1710989025",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "DODENHOFF",
"FirstName": "ROBERT",
"MiddleName": "M",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-832-8150",
"MailingAddressFaxNumber": "860-224-6298",
"FirstLinePracticeLocationAddress": "300 KENSINGTON AVE",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06051-3916",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-832-8150",
"PracticeLocationAddressFaxNumber": "860-224-6298",
"EnumerationDate": "06/01/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207R00000X",
"Taxonomy1": "Internal Medicine Physician",
"LicenseNumber1": "028303",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "010028303CT01",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "BCBS PROVIDER ID",
"OtherIdentifier2": "004215324",
"OtherIdentifierType2": "MEDICAID",
"OtherIdentifierState2": "CT",
"OtherIdentifier3": "02830301",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "CONNECTICARE ID",
"OtherIdentifier4": "477150",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "AENTA PROVIDER ID REF",
"OtherIdentifier5": "912613",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "HEALTH NET REF ID",
"OtherIdentifier6": "01028303",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "CIGNA PROVIDER ID",
"OtherIdentifier7": "P369832",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "OXFORD PROVIDER ID",
"OtherIdentifier8": "001283035",
"OtherIdentifierType8": "MEDICAID",
"OtherIdentifierState8": "CT",
"OtherIdentifier9": "060080",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "HEALTH NET PROVIDER ID",
"OtherIdentifier10": "1255448155",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "GHMC GRP NPI ID",
"OtherIdentifier11": "010028303CT01",
"OtherIdentifierType11": "OTHER",
"OtherIdentifierState11": "CT",
"OtherIdentifierIssuer11": "BCFP PROVIDER ID",
"PrimaryTaxonomyCode": "207R00000X",
"PrimaryTaxonomy": "Internal Medicine Physician"
},
{
"NPI": "1760484067",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "DREISS",
"FirstName": "RICHARD",
"MiddleName": "J",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-224-6205",
"MailingAddressFaxNumber": "860-826-4957",
"FirstLinePracticeLocationAddress": "300 KENSINGTON AVE",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06051-3916",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-224-6205",
"PracticeLocationAddressFaxNumber": "860-826-4957",
"EnumerationDate": "06/01/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207V00000X",
"Taxonomy1": "Obstetrics & Gynecology Physician",
"LicenseNumber1": "026770",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "P369885",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "OXFORD PROV ID",
"OtherIdentifier2": "060086",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "HEALTH NET PROV ID",
"OtherIdentifier3": "3062401",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "CONNECTICARE ID",
"OtherIdentifier4": "01026770",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "CIGNA PROV ID",
"OtherIdentifier5": "487984",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "AETNA REF ID",
"OtherIdentifier6": "010026770CT01",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "BCBS N BCFP PROV ID",
"OtherIdentifier7": "1255448155",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "GHMC GROUP NPI",
"OtherIdentifier8": "367557",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "WELLCARE MEDICARE ONLY",
"PrimaryTaxonomyCode": "207V00000X",
"PrimaryTaxonomy": "Obstetrics & Gynecology Physician"
},
{
"NPI": "1558363846",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "FALLON",
"FirstName": "BARBARA",
"MiddleName": "G",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3999",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-224-6254",
"MailingAddressFaxNumber": "860-832-4378",
"FirstLinePracticeLocationAddress": "300 KENSINGTON AVE",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06051-3916",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-224-6254",
"PracticeLocationAddressFaxNumber": "860-832-4378",
"EnumerationDate": "06/01/2005",
"LastUpdateDate": "02/25/2010",
"GenderCode": "F",
"Gender": "Female",
"TaxonomyCode1": "207RX0202X",
"Taxonomy1": "Medical Oncology Physician",
"LicenseNumber1": "029598",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "004062394",
"OtherIdentifierType1": "MEDICAID",
"OtherIdentifierState1": "CT",
"OtherIdentifier2": "367807",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "WELLCARE MEDICARE",
"OtherIdentifier3": "4377459",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "AETNA REF ID",
"OtherIdentifier4": "HAS407",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "HEALTH NET PROV ID",
"OtherIdentifier5": "010029598CT02",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "BCBS N BCFP PROV ID",
"OtherIdentifier6": "720988",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "CONNECTICARE PROV ID",
"OtherIdentifier7": "2V3633",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "HEALTH NET PROV ID",
"OtherIdentifier8": "001295981",
"OtherIdentifierType8": "MEDICAID",
"OtherIdentifierState8": "CT",
"OtherIdentifier9": "0029365",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "CIGNA PROV ID",
"OtherIdentifier10": "1255448155",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "GHMC GROUP NPI",
"PrimaryTaxonomyCode": "207RX0202X",
"PrimaryTaxonomy": "Medical Oncology Physician"
},
{
"NPI": "1871595157",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "FEINGLASS",
"FirstName": "EDWARD",
"MiddleName": "J",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-612-0485",
"MailingAddressFaxNumber": "860-224-0766",
"FirstLinePracticeLocationAddress": "300 KENSINGTON AVE",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06051-3916",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-612-0485",
"PracticeLocationAddressFaxNumber": "860-224-0766",
"EnumerationDate": "06/01/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207RR0500X",
"Taxonomy1": "Rheumatology Physician",
"LicenseNumber1": "017777",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "1255448155",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "GHMC NPI ID",
"OtherIdentifier2": "001177773",
"OtherIdentifierType2": "MEDICAID",
"OtherIdentifierState2": "CT",
"OtherIdentifier3": "41740",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "AETNA REF ID",
"OtherIdentifier4": "060047",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "HEALTH NET PROV ID",
"OtherIdentifier5": "004062394",
"OtherIdentifierType5": "MEDICAID",
"OtherIdentifierState5": "CT",
"OtherIdentifier6": "010017777CT03",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "BCBS N BCFP PROV ID",
"OtherIdentifier7": "367845",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "WELLCARE MEDICARE",
"OtherIdentifier8": "P369968",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "OXFORD PROVIDER ID",
"OtherIdentifier9": "912442",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "HEALTH NET REF ID",
"OtherIdentifier10": "01217777",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "CIGNA PROV ID",
"OtherIdentifier11": "5926402",
"OtherIdentifierType11": "OTHER",
"OtherIdentifierState11": "CT",
"OtherIdentifierIssuer11": "CONNECTICARE PROV ID",
"PrimaryTaxonomyCode": "207RR0500X",
"PrimaryTaxonomy": "Rheumatology Physician"
},
{
"NPI": "1144222415",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "FITZPATRICK",
"FirstName": "EDWARD",
"MiddleName": "P",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-826-4460",
"MailingAddressFaxNumber": "860-224-6260",
"FirstLinePracticeLocationAddress": "1 LAKE ST",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06052-1396",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-826-4460",
"PracticeLocationAddressFaxNumber": "860-826-4436",
"EnumerationDate": "06/01/2005",
"LastUpdateDate": "05/13/2008",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207W00000X",
"Taxonomy1": "Ophthalmology Physician",
"LicenseNumber1": "035599",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "035599-1831",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "CONNECTICARE MERIDEN",
"OtherIdentifier2": "1255448155",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "GHMC GRP NPI ID",
"OtherIdentifier3": "004214433",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "GHMC GRP CAID ID",
"OtherIdentifier4": "060173",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "HEALTH NET PROV ID",
"OtherIdentifier5": "CT5599",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "EYE MED VISION CARE",
"OtherIdentifier6": "035599-3714",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "CONNECTICARE NB LOCATION",
"OtherIdentifier7": "136392",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "WELLCARE MEDICARE",
"OtherIdentifier8": "010035599CT01",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "BCBS NB LOCATION",
"OtherIdentifier9": "010035599CT03",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "BCBS MERIDEN LOCATION",
"OtherIdentifier10": "914443",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "BLOCK VISION ID",
"OtherIdentifier11": "C01373",
"OtherIdentifierType11": "OTHER",
"OtherIdentifierState11": "CT",
"OtherIdentifierIssuer11": "GHMC GRP MEDICARE ID",
"OtherIdentifier12": "P422705",
"OtherIdentifierType12": "OTHER",
"OtherIdentifierState12": "CT",
"OtherIdentifierIssuer12": "OXFORD ID",
"OtherIdentifier13": "932774",
"OtherIdentifierType13": "OTHER",
"OtherIdentifierState13": "CT",
"OtherIdentifierIssuer13": "HEALTH NET REF ID",
"OtherIdentifier14": "01035599",
"OtherIdentifierType14": "OTHER",
"OtherIdentifierState14": "CT",
"OtherIdentifierIssuer14": "CIGNA PROV ID",
"OtherIdentifier15": "5907379",
"OtherIdentifierType15": "OTHER",
"OtherIdentifierState15": "CT",
"OtherIdentifierIssuer15": "AETNA REF ID",
"OtherIdentifier16": "001355991",
"OtherIdentifierType16": "MEDICAID",
"OtherIdentifierState16": "CT",
"PrimaryTaxonomyCode": "207W00000X",
"PrimaryTaxonomy": "Ophthalmology Physician"
},
{
"NPI": "1285639013",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "FROST",
"FirstName": "HOLLY",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "1570 FRUITVILLE PIKE STE 100",
"MailingAddressCityName": "LANCASTER",
"MailingAddressStateName": "PA",
"MailingAddressPostalCode": "17601-4087",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "717-569-6481",
"MailingAddressFaxNumber": "717-569-5213",
"FirstLinePracticeLocationAddress": "1570 FRUITVILLE PIKE STE 100",
"PracticeLocationAddressCityName": "LANCASTER",
"PracticeLocationAddressStateName": "PA",
"PracticeLocationAddressPostalCode": "17601-4087",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "717-569-6481",
"PracticeLocationAddressFaxNumber": "717-569-5213",
"EnumerationDate": "06/17/2005",
"LastUpdateDate": "09/21/2020",
"GenderCode": "F",
"Gender": "Female",
"TaxonomyCode1": "208000000X",
"Taxonomy1": "Pediatrics Physician",
"LicenseNumber1": "MD033691E",
"LicenseNumberStateCode1": "PA",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "2658530",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "AETNA REF ID",
"OtherIdentifier2": "010039781CT01",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "BCBS N BCFP PROV ID",
"OtherIdentifier3": "004195930",
"OtherIdentifierType3": "MEDICAID",
"OtherIdentifierState3": "CT",
"OtherIdentifier4": "0874481-003",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "CIGNA ID",
"OtherIdentifier5": "0V0463",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "HEALTH NET ID",
"OtherIdentifier6": "1255448155",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "GHMC GRP NPI ID",
"OtherIdentifier7": "060916784-003",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "TRICARE HNFS ID",
"OtherIdentifier8": "759412",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "CONNECTICARE ID",
"OtherIdentifier9": "P2543273",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "OXFORD ID",
"OtherIdentifier10": "001397810",
"OtherIdentifierType10": "MEDICAID",
"OtherIdentifierState10": "CT",
"CertificationDate": "09/21/2020",
"PrimaryTaxonomyCode": "208000000X",
"PrimaryTaxonomy": "Pediatrics Physician"
},
{
"NPI": "1316943285",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "GEDDIS",
"FirstName": "ANGELA",
"MiddleName": "G",
"NamePrefix": "DR.",
"Credential": "M.D.",
"OtherLastName": "LORD",
"OtherFirstName": "ANGELA",
"OtherMiddleName": "G.",
"OtherNamePrefix": "DR.",
"OtherCredential": "M.D.",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-224-6282",
"MailingAddressFaxNumber": "860-826-4959",
"FirstLinePracticeLocationAddress": "184 EAST ST",
"PracticeLocationAddressCityName": "PLAINVILLE",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06062-2913",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-747-1132",
"PracticeLocationAddressFaxNumber": "860-747-2028",
"EnumerationDate": "06/24/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "F",
"Gender": "Female",
"TaxonomyCode1": "208000000X",
"Taxonomy1": "Pediatrics Physician",
"LicenseNumber1": "031048",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "060040",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "HEALTH NET ID",
"OtherIdentifier2": "1255448155",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "GHMC NPI ID",
"OtherIdentifier3": "476805",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "AETNA REF ID",
"OtherIdentifier4": "010031048CT03",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "BCBS NBCFP PLAINVILLE ID",
"OtherIdentifier5": "010031048CT04",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "BCBSN BCFP NB ID",
"OtherIdentifier6": "01031048",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "CIGNA ID",
"OtherIdentifier7": "912429",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "HEALTH NET REF ID",
"OtherIdentifier8": "71668401",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "CONNECTICARE ID",
"OtherIdentifier9": "P369863",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "OXFORD ID",
"OtherIdentifier10": "126638",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "WELLCARE MEDICARE",
"PrimaryTaxonomyCode": "208000000X",
"PrimaryTaxonomy": "Pediatrics Physician"
},
{
"NPI": "1013913995",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "GENOVESI",
"FirstName": "MICHAEL",
"MiddleName": "G.",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-224-6266",
"MailingAddressFaxNumber": "860-224-6269",
"FirstLinePracticeLocationAddress": "300 KENSINGTON AVE",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06051-3916",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-224-6266",
"PracticeLocationAddressFaxNumber": "860-224-6269",
"EnumerationDate": "06/24/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207RP1001X",
"Taxonomy1": "Pulmonary Disease Physician",
"LicenseNumber1": "18248",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "912409",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "HEALTH NET REF ID",
"OtherIdentifier2": "004062394",
"OtherIdentifierType2": "MEDICAID",
"OtherIdentifierState2": "CT",
"OtherIdentifier3": "010018248CT01",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "BCBS N BCFP PROV ID",
"OtherIdentifier4": "059108-1631",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "CONNECTICARE ID",
"OtherIdentifier5": "001182484",
"OtherIdentifierType5": "MEDICAID",
"OtherIdentifierState5": "CT",
"OtherIdentifier6": "01018248",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "CIGNA PROV ID",
"OtherIdentifier7": "060028",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "HEALTH NET PROV ID",
"OtherIdentifier8": "135689",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "WELLCARE MEDICARE",
"OtherIdentifier9": "476841",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "AETNA REF ID",
"OtherIdentifier10": "P369819",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "OXFORD ID",
"OtherIdentifier11": "1255448155",
"OtherIdentifierType11": "OTHER",
"OtherIdentifierState11": "CT",
"OtherIdentifierIssuer11": "GHMC GRP NPI ID",
"PrimaryTaxonomyCode": "207RP1001X",
"PrimaryTaxonomy": "Pulmonary Disease Physician"
},
{
"NPI": "1790781672",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "GERRATANA",
"FirstName": "FRANK",
"MiddleName": "J",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-832-4666",
"MailingAddressFaxNumber": "860-348-4931",
"FirstLinePracticeLocationAddress": "73 CEDAR ST",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06052-1390",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-832-4666",
"PracticeLocationAddressFaxNumber": "860-348-4931",
"EnumerationDate": "06/24/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207X00000X",
"Taxonomy1": "Orthopaedic Surgery Physician",
"LicenseNumber1": "017439",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "010017439CT01",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "BCBS N BCFP PROV ID",
"OtherIdentifier2": "01027439",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "CIGNA PROV ID",
"OtherIdentifier3": "060112",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "HEALTH NET PROV ID",
"OtherIdentifier4": "1255448155",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "GHMCGROUP NPI AFFILIATION",
"OtherIdentifier5": "P369862",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "OXFORD PROV ID",
"OtherIdentifier6": "004214425",
"OtherIdentifierType6": "MEDICAID",
"OtherIdentifierState6": "CT",
"OtherIdentifier7": "001174390",
"OtherIdentifierType7": "MEDICAID",
"OtherIdentifierState7": "CT",
"OtherIdentifier8": "275569",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "WELLCARE MEDICARE",
"OtherIdentifier9": "1255448155",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "GHMC GRP NPI ID",
"OtherIdentifier10": "060291",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "CONNECTICARE PROV ID",
"OtherIdentifier11": "84073",
"OtherIdentifierType11": "OTHER",
"OtherIdentifierState11": "CT",
"OtherIdentifierIssuer11": "AETNA REF ID",
"PrimaryTaxonomyCode": "207X00000X",
"PrimaryTaxonomy": "Orthopaedic Surgery Physician"
},
{
"NPI": "1457357246",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "HARRIS",
"FirstName": "PETER",
"MiddleName": "J",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-747-5766",
"MailingAddressFaxNumber": "860-747-2028",
"FirstLinePracticeLocationAddress": "184 EAST ST",
"PracticeLocationAddressCityName": "PLAINVILLE",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06062-2913",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-747-5766",
"PracticeLocationAddressFaxNumber": "860-747-2028",
"EnumerationDate": "06/27/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207R00000X",
"Taxonomy1": "Internal Medicine Physician",
"LicenseNumber1": "037834",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "2151393",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "CIGNA PROVIDER ID",
"OtherIdentifier2": "369674",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "WELLCARE MEDICARE",
"OtherIdentifier3": "001378349",
"OtherIdentifierType3": "MEDICAID",
"OtherIdentifierState3": "CT",
"OtherIdentifier4": "010037834CT02",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "BCBS N BCFP PROV ID",
"OtherIdentifier5": "004215324",
"OtherIdentifierType5": "MEDICAID",
"OtherIdentifierState5": "CT",
"OtherIdentifier6": "01037834",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "CIGNA PROV ID",
"OtherIdentifier7": "037834",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "CONNECTICARE ID",
"OtherIdentifier8": "1255448155",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "GHMC GROUP NPI ID",
"OtherIdentifier9": "P1853296",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "OXFORD PROV ID",
"OtherIdentifier10": "0V5889",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "HEALTH NET PROV ID",
"PrimaryTaxonomyCode": "207R00000X",
"PrimaryTaxonomy": "Internal Medicine Physician"
},
{
"NPI": "1275539066",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "HAVERLY",
"FirstName": "KAREN",
"MiddleName": "P",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-747-0730",
"MailingAddressFaxNumber": "860-747-2028",
"FirstLinePracticeLocationAddress": "184 EAST ST",
"PracticeLocationAddressCityName": "PLAINVILLE",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06062-2913",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-747-5766",
"PracticeLocationAddressFaxNumber": "860-747-2028",
"EnumerationDate": "06/27/2005",
"LastUpdateDate": "07/08/2007",
"GenderCode": "F",
"Gender": "Female",
"TaxonomyCode1": "207V00000X",
"Taxonomy1": "Obstetrics & Gynecology Physician",
"LicenseNumber1": "030435",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "004196095",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "GHMC GRP MEDICAID ID",
"OtherIdentifier2": "01030435",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "CIGNA PROV ID",
"OtherIdentifier3": "001304352",
"OtherIdentifierType3": "MEDICAID",
"OtherIdentifierState3": "CT",
"OtherIdentifier4": "060025",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "HEALTH NET PROV ID",
"OtherIdentifier5": "060916784-042",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "TRICARE HNFS PROV ID",
"OtherIdentifier6": "135451",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "WELLCARE MEDICARE",
"OtherIdentifier7": "P369881",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "OXFORD PROV ID",
"OtherIdentifier8": "3043501",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "CONNECTICARE PROV ID",
"OtherIdentifier9": "912397",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "HEALTH NET REF ID",
"OtherIdentifier10": "010030435CT01",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "BCBS N BCFP PROV ID",
"OtherIdentifier11": "1255448155",
"OtherIdentifierType11": "OTHER",
"OtherIdentifierState11": "CT",
"OtherIdentifierIssuer11": "GHMC NPI ID",
"OtherIdentifier12": "482028",
"OtherIdentifierType12": "OTHER",
"OtherIdentifierState12": "CT",
"OtherIdentifierIssuer12": "AETNA PROV ID",
"PrimaryTaxonomyCode": "207V00000X",
"PrimaryTaxonomy": "Obstetrics & Gynecology Physician"
},
{
"NPI": "1497751168",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "HOLMES",
"FirstName": "CATHERINE",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-832-8150",
"MailingAddressFaxNumber": "860-224-6953",
"FirstLinePracticeLocationAddress": "300 KENSINGTON AVE",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06051-3916",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-832-8150",
"PracticeLocationAddressFaxNumber": "860-224-6953",
"EnumerationDate": "06/27/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "F",
"Gender": "Female",
"TaxonomyCode1": "207R00000X",
"Taxonomy1": "Internal Medicine Physician",
"LicenseNumber1": "040511",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "001405118",
"OtherIdentifierType1": "MEDICAID",
"OtherIdentifierState1": "CT",
"OtherIdentifier2": "010040511CT01",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "BCBS N BCFP PROV ID",
"OtherIdentifier3": "1255448155",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "GHMC GRP NPI ID",
"OtherIdentifier4": "P2720404",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "OXFORD PROV ID",
"OtherIdentifier5": "004215324",
"OtherIdentifierType5": "MEDICAID",
"OtherIdentifierState5": "CT",
"OtherIdentifier6": "7542369",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "AETNA REF ID",
"OtherIdentifier7": "C01373",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "GHMC GRP MEDICARE ID",
"OtherIdentifier8": "040511",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "CONNECTICARE PROV ID",
"OtherIdentifier9": "2V2142",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "HEALTH NET PROV ID",
"OtherIdentifier10": "1308844",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "CIGNA PROV ID",
"OtherIdentifier11": "368438",
"OtherIdentifierType11": "OTHER",
"OtherIdentifierState11": "CT",
"OtherIdentifierIssuer11": "WELLCARE MEDICARE",
"PrimaryTaxonomyCode": "207R00000X",
"PrimaryTaxonomy": "Internal Medicine Physician"
},
{
"NPI": "1073519658",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "HUSSAIN",
"FirstName": "SHAHNAZ",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-667-1244",
"MailingAddressFaxNumber": "860-666-5153",
"FirstLinePracticeLocationAddress": "18 CEDAR ST",
"PracticeLocationAddressCityName": "NEWINGTON",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06111-2647",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-667-1244",
"PracticeLocationAddressFaxNumber": "860-666-5153",
"EnumerationDate": "06/28/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "F",
"Gender": "Female",
"TaxonomyCode1": "207R00000X",
"Taxonomy1": "Internal Medicine Physician",
"LicenseNumber1": "024449",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "C01373",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "GHMC GRP MEDICARE ID",
"OtherIdentifier2": "P1252377",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "OXFORD PROV ID",
"OtherIdentifier3": "010024449CT04",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "BCBS N BCFP PROV ID",
"OtherIdentifier4": "050040",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "CONNECTICARE PROV ID",
"OtherIdentifier5": "0V4120",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "HEALTH NET PROV ID",
"OtherIdentifier6": "1255448155",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "GHMC GRP NPI ID",
"OtherIdentifier7": "103714",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "WELLCARE MEDICARE",
"OtherIdentifier8": "581417",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "AETNA REF ID",
"OtherIdentifier9": "001244490",
"OtherIdentifierType9": "MEDICAID",
"OtherIdentifierState9": "CT",
"OtherIdentifier10": "004215324",
"OtherIdentifierType10": "MEDICAID",
"OtherIdentifierState10": "CT",
"OtherIdentifier11": "01024449",
"OtherIdentifierType11": "OTHER",
"OtherIdentifierState11": "CT",
"OtherIdentifierIssuer11": "CIGNA PROV ID",
"OtherIdentifier12": "110178633",
"OtherIdentifierType12": "OTHER",
"OtherIdentifierState12": "CT",
"OtherIdentifierIssuer12": "RAIL ROAD MEDICARE ID",
"PrimaryTaxonomyCode": "207R00000X",
"PrimaryTaxonomy": "Internal Medicine Physician"
},
{
"NPI": "1831196161",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "HONOR",
"FirstName": "MICHAEL",
"MiddleName": "S",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"SecondLineMailingAddress": "GROVE HILL MEDICAL CENTER",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-832-8150",
"MailingAddressFaxNumber": "860-224-6953",
"FirstLinePracticeLocationAddress": "300 KENSINGTON AVE",
"SecondLinePracticeLocationAddress": "GROVE HILL MEDICAL CENTER",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06051-3916",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-832-8150",
"PracticeLocationAddressFaxNumber": "860-224-6953",
"EnumerationDate": "07/01/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207R00000X",
"Taxonomy1": "Internal Medicine Physician",
"LicenseNumber1": "030186",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "01030186",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "CIGNA PROV ID",
"OtherIdentifier2": "912410",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "HEALTH NET REF ID",
"OtherIdentifier3": "001301861",
"OtherIdentifierType3": "MEDICAID",
"OtherIdentifierState3": "CT",
"OtherIdentifier4": "010030186CT02",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "BCBS N BCFP PROV ID",
"OtherIdentifier5": "060029",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "HEALTH NET PROV ID",
"OtherIdentifier6": "135692",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "WELLCARE MEDICARE",
"OtherIdentifier7": "476793",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "AETNA REF ID",
"OtherIdentifier8": "1255448155",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "GHMC GRP NPI ID",
"OtherIdentifier9": "73678401",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "CONNECTICARE PROV ID",
"OtherIdentifier10": "P369813",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "OXFORD PROV ID",
"OtherIdentifier11": "004215324",
"OtherIdentifierType11": "MEDICAID",
"OtherIdentifierState11": "CT",
"PrimaryTaxonomyCode": "207R00000X",
"PrimaryTaxonomy": "Internal Medicine Physician"
},
{
"NPI": "1639177629",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "KEMLER",
"FirstName": "BARRY",
"MiddleName": "J",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"SecondLineMailingAddress": "GROVE HILL MEDICAL CENTER",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-224-6249",
"MailingAddressFaxNumber": "860-224-6241",
"FirstLinePracticeLocationAddress": "300 KENSINGTON AVE",
"SecondLinePracticeLocationAddress": "GROVE HILL MEDICAL CENTER",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06051-3916",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-224-6249",
"PracticeLocationAddressFaxNumber": "860-224-6241",
"EnumerationDate": "07/13/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207RG0100X",
"Taxonomy1": "Gastroenterology Physician",
"LicenseNumber1": "22221",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "001222215",
"OtherIdentifierType1": "MEDICAID",
"OtherIdentifierState1": "CT",
"OtherIdentifier2": "010022221CT01",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "BCBS N BCFP PROV ID",
"OtherIdentifier3": "060054",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "HEALTH NET PROV ID",
"OtherIdentifier4": "P369967",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "OXFORD PROV ID",
"OtherIdentifier5": "5405001",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "CONNECTICARE PROV ID",
"OtherIdentifier6": "71141",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "AETNA REF ID",
"OtherIdentifier7": "912454",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "HEALTH NET REF ID",
"OtherIdentifier8": "01022221",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "CIGNA PROV ID",
"OtherIdentifier9": "1255448155",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "GHMC GRP NPI ID",
"OtherIdentifier10": "367630",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "WELLCARE MEDICARE",
"OtherIdentifier11": "004062394",
"OtherIdentifierType11": "MEDICAID",
"OtherIdentifierState11": "CT",
"PrimaryTaxonomyCode": "207RG0100X",
"PrimaryTaxonomy": "Gastroenterology Physician"
},
{
"NPI": "1558369561",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "INSEL",
"FirstName": "JARED",
"MiddleName": "M",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-223-0220",
"MailingAddressFaxNumber": "860-826-4962",
"FirstLinePracticeLocationAddress": "1 LAKE ST",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06052-1396",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-223-0220",
"PracticeLocationAddressFaxNumber": "860-826-4962",
"EnumerationDate": "07/13/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207RC0000X",
"Taxonomy1": "Cardiovascular Disease Physician",
"LicenseNumber1": "24813",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "139484",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "WELLCARE MEDICARE",
"OtherIdentifier2": "001248137",
"OtherIdentifierType2": "MEDICAID",
"OtherIdentifierState2": "CT",
"OtherIdentifier3": "010024813CT01",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "BCBS N BCFP PROV ID",
"OtherIdentifier4": "481462",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "AETNA REF ID",
"OtherIdentifier5": "01024813",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "CIGNA PROV ID",
"OtherIdentifier6": "01908387",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "NY",
"OtherIdentifierIssuer6": "NY MEDICAID",
"OtherIdentifier7": "004214459",
"OtherIdentifierType7": "MEDICAID",
"OtherIdentifierState7": "CT",
"OtherIdentifier8": "1255448155",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "GHMC GRP NPI ID",
"OtherIdentifier9": "5004101",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "CONNECTICARE PROV ID",
"OtherIdentifier10": "P369914",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "OXFORD PROV ID",
"PrimaryTaxonomyCode": "207RC0000X",
"PrimaryTaxonomy": "Cardiovascular Disease Physician"
},
{
"NPI": "1841298841",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "KERRIGAN",
"FirstName": "KIRSTEN",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"SecondLineMailingAddress": "GROVE HILL MEDICAL CENTER",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-666-5111",
"MailingAddressFaxNumber": "860-666-5153",
"FirstLinePracticeLocationAddress": "18 CEDAR ST",
"SecondLinePracticeLocationAddress": "GROVE HILL MEDICAL CENTER",
"PracticeLocationAddressCityName": "NEWINGTON",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06111-2647",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-666-5111",
"PracticeLocationAddressFaxNumber": "860-666-5153",
"EnumerationDate": "07/13/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "F",
"Gender": "Female",
"TaxonomyCode1": "207V00000X",
"Taxonomy1": "Obstetrics & Gynecology Physician",
"LicenseNumber1": "041391",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "5281217",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "CIGNA PROV ID",
"OtherIdentifier2": "369989",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "WELLCARE MEDICARE",
"OtherIdentifier3": "P3292477",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "OXFORD PROV ID",
"OtherIdentifier4": "010041391CT02",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "BCBS N BCFP PROV ID",
"OtherIdentifier5": "041391",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "CONNECTICARE PROV ID",
"OtherIdentifier6": "7193539",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "AETNA REF ID",
"OtherIdentifier7": "03648049",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "AETNA PROV ID",
"OtherIdentifier8": "1255448155",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "GHMC GRP NPI ID",
"OtherIdentifier9": "2V2669",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "HEALTH NET PROV ID",
"PrimaryTaxonomyCode": "207V00000X",
"PrimaryTaxonomy": "Obstetrics & Gynecology Physician"
},
{
"NPI": "1932107851",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "KAPLAN",
"FirstName": "KEITH",
"MiddleName": "A",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-826-4453",
"MailingAddressFaxNumber": "860-826-6219",
"FirstLinePracticeLocationAddress": "1 LAKE ST",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06052-1396",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-826-4453",
"PracticeLocationAddressFaxNumber": "860-826-6219",
"EnumerationDate": "07/13/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "208800000X",
"Taxonomy1": "Urology Physician",
"LicenseNumber1": "028317",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "060068",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "HEALTH NET PROV ID",
"OtherIdentifier2": "010028317CT01",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "BCBS N BCFP PRIM ID",
"OtherIdentifier3": "010028317CT04",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "BCBS N BCFP 2LOCA PROV ID",
"OtherIdentifier4": "01028317",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "CIGNA PROV ID",
"OtherIdentifier5": "1255448155",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "GHMC GRP NPI ID",
"OtherIdentifier6": "340010375",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "RAIL ROAD MEDICARE ID",
"OtherIdentifier7": "912457",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "HEALTH NET REF ID",
"OtherIdentifier8": "135455",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "WELLCARE MEDICARE",
"OtherIdentifier9": "P369843",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "OXFORD PROV ID",
"OtherIdentifier10": "001283176",
"OtherIdentifierType10": "MEDICAID",
"OtherIdentifierState10": "CT",
"OtherIdentifier11": "004214467",
"OtherIdentifierType11": "MEDICAID",
"OtherIdentifierState11": "CT",
"OtherIdentifier12": "71678001",
"OtherIdentifierType12": "OTHER",
"OtherIdentifierState12": "CT",
"OtherIdentifierIssuer12": "CONNECTICARE PROV ID",
"OtherIdentifier13": "70801",
"OtherIdentifierType13": "OTHER",
"OtherIdentifierState13": "CT",
"OtherIdentifierIssuer13": "AETNA REF ID",
"PrimaryTaxonomyCode": "208800000X",
"PrimaryTaxonomy": "Urology Physician"
},
{
"NPI": "1407854276",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "KUDLER",
"FirstName": "ALAN",
"MiddleName": "M",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"SecondLineMailingAddress": "GROVE HILL MEDICAL CENTER",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-223-0220",
"MailingAddressFaxNumber": "860-826-4962",
"FirstLinePracticeLocationAddress": "1 LAKE ST",
"SecondLinePracticeLocationAddress": "GROVE HILL MEDICAL CENTER",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06052-1396",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-223-0220",
"PracticeLocationAddressFaxNumber": "860-826-4962",
"EnumerationDate": "07/14/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207RC0000X",
"Taxonomy1": "Cardiovascular Disease Physician",
"LicenseNumber1": "021718",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "1255448155",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "GHMC GRP NPI ID",
"OtherIdentifier2": "5240601",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "CONNECTICARE PROV ID",
"OtherIdentifier3": "135460",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "WELLCARE MEDICARE",
"OtherIdentifier4": "01021718",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "CIGNA PROV ID",
"OtherIdentifier5": "P369906",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "OXFORD PROV ID",
"OtherIdentifier6": "001217181",
"OtherIdentifierType6": "MEDICAID",
"OtherIdentifierState6": "CT",
"OtherIdentifier7": "060049",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "HEALTH NET PROV ID",
"OtherIdentifier8": "481464",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "AETNA PROV ID",
"OtherIdentifier9": "912449",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "HEALTH NET REF ID",
"OtherIdentifier10": "004214459",
"OtherIdentifierType10": "MEDICAID",
"OtherIdentifierState10": "CT",
"PrimaryTaxonomyCode": "207RC0000X",
"PrimaryTaxonomy": "Cardiovascular Disease Physician"
},
{
"NPI": "1750389524",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "MANTHOUS",
"FirstName": "PAMELA",
"MiddleName": "L",
"NamePrefix": "DR.",
"Credential": "M.D.",
"OtherLastName": "BALLING",
"OtherFirstName": "PAMELA",
"OtherMiddleName": "L",
"OtherNamePrefix": "DR.",
"OtherCredential": "M.D.",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"SecondLineMailingAddress": "GROVE HILL MEDICAL CENTER",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-666-5111",
"MailingAddressFaxNumber": "860-666-5153",
"FirstLinePracticeLocationAddress": "18 CEDAR ST",
"SecondLinePracticeLocationAddress": "GROVE HILL MEDICAL CENTER",
"PracticeLocationAddressCityName": "NEWINGTON",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06111-2647",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-666-5111",
"PracticeLocationAddressFaxNumber": "860-666-5153",
"EnumerationDate": "07/14/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "F",
"Gender": "Female",
"TaxonomyCode1": "207VG0400X",
"Taxonomy1": "Gynecology Physician",
"LicenseNumber1": "032643",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "3264301",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "CONNECTICARE PROV ID",
"OtherIdentifier2": "368783",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "WELLCARE MEDICARE",
"OtherIdentifier3": "912607",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "HEALTH NET REF ID",
"OtherIdentifier4": "010032643CT",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "BCBS N BCFP PROV ID",
"OtherIdentifier5": "01032643",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "CIGNA PROV ID",
"OtherIdentifier6": "060074",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "HEALTH NET PROV ID",
"OtherIdentifier7": "004196095",
"OtherIdentifierType7": "MEDICAID",
"OtherIdentifierState7": "CT",
"OtherIdentifier8": "1255448155",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "GHMC GRP NPI PROV ID",
"OtherIdentifier9": "500222",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "AETNA PROV ID",
"OtherIdentifier10": "P369849",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "OXFORD PROV ID",
"OtherIdentifier11": "001326439",
"OtherIdentifierType11": "MEDICAID",
"OtherIdentifierState11": "CT",
"PrimaryTaxonomyCode": "207VG0400X",
"PrimaryTaxonomy": "Gynecology Physician"
},
{
"NPI": "1912906579",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "MIHALEK",
"FirstName": "JEFFREY",
"MiddleName": "J",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"SecondLineMailingAddress": "GROVE HILL MEDICAL CENTER",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-666-5111",
"MailingAddressFaxNumber": "860-666-5153",
"FirstLinePracticeLocationAddress": "375 WILLARD AVE",
"SecondLinePracticeLocationAddress": "GROVE HILL MEDICAL CENTER",
"PracticeLocationAddressCityName": "NEWINGTON",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06111-2300",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-666-5111",
"PracticeLocationAddressFaxNumber": "860-666-5153",
"EnumerationDate": "07/18/2005",
"LastUpdateDate": "03/09/2012",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207V00000X",
"Taxonomy1": "Obstetrics & Gynecology Physician",
"LicenseNumber1": "035025",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "001350256",
"OtherIdentifierType1": "MEDICAID",
"OtherIdentifierState1": "CT",
"OtherIdentifier2": "01035025",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "CIGNA PROV ID",
"OtherIdentifier3": "134928",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "WELLCARE MEDICARE",
"OtherIdentifier4": "550419",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "AETNA PROV ID",
"OtherIdentifier5": "010035025CT02",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "BCBS N BCFP PROV ID",
"OtherIdentifier6": "004196095",
"OtherIdentifierType6": "MEDICAID",
"OtherIdentifierState6": "CT",
"OtherIdentifier7": "P369900",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "OXFORD PROV ID",
"OtherIdentifier8": "060121",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "HEALTH NET PROV ID",
"OtherIdentifier9": "1255448155",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "GHMC GRP NPI ID",
"OtherIdentifier10": "350250",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "CONNECTICARE PROV ID",
"PrimaryTaxonomyCode": "207V00000X",
"PrimaryTaxonomy": "Obstetrics & Gynecology Physician"
},
{
"NPI": "1639178296",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "MIHALEK",
"FirstName": "MARY",
"MiddleName": "E",
"NamePrefix": "DR.",
"Credential": "M.D.",
"OtherLastName": "ARMINGTON",
"OtherFirstName": "MARY",
"OtherMiddleName": "E",
"OtherNamePrefix": "DR.",
"OtherCredential": "M.D.",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"SecondLineMailingAddress": "GROVE HILL MEDICAL CENTER",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-224-6215",
"MailingAddressFaxNumber": "860-826-4957",
"FirstLinePracticeLocationAddress": "300 KENSINGTON AVE",
"SecondLinePracticeLocationAddress": "GROVE HILL MEDICAL CENTER",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06051-3916",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-224-6215",
"PracticeLocationAddressFaxNumber": "860-826-4957",
"EnumerationDate": "07/18/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "F",
"Gender": "Female",
"TaxonomyCode1": "207V00000X",
"Taxonomy1": "Obstetrics & Gynecology Physician",
"LicenseNumber1": "036746",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "010036746CT02",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "BCBS N BCFP PROV ID",
"OtherIdentifier2": "0V5162",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "HEALTH NET PROV ID",
"OtherIdentifier3": "CL00041",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "OXFORD PROV ID",
"OtherIdentifier4": "1255448155",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "GHMC GRP NPI ID",
"OtherIdentifier5": "2171905",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "AETNA PROV ID",
"OtherIdentifier6": "368089",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "WELLCARE MEDCIARE",
"OtherIdentifier7": "036746",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "CONNECTICARE PROV ID",
"OtherIdentifier8": "01036746",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "CIGNA PROV ID",
"PrimaryTaxonomyCode": "207V00000X",
"PrimaryTaxonomy": "Obstetrics & Gynecology Physician"
},
{
"NPI": "1710986377",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "MCAULIFFE",
"FirstName": "GERALD",
"MiddleName": "V",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "300 KENSINGTON AVE",
"SecondLineMailingAddress": "GROVE HILL MEDICAL CENTER",
"MailingAddressCityName": "NEW BRITAIN",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06051-3916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-832-8150",
"MailingAddressFaxNumber": "860-224-6953",
"FirstLinePracticeLocationAddress": "300 KENSINGTON AVE",
"SecondLinePracticeLocationAddress": "GROVE HILL MEDICAL CENTER",
"PracticeLocationAddressCityName": "NEW BRITAIN",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06051-3916",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-832-8150",
"PracticeLocationAddressFaxNumber": "860-224-6953",
"EnumerationDate": "07/18/2005",
"LastUpdateDate": "07/09/2007",
"GenderCode": "M",
"Gender": "Male",
"TaxonomyCode1": "207R00000X",
"Taxonomy1": "Internal Medicine Physician",
"LicenseNumber1": "018392",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "060107",
"OtherIdentifierType1": "OTHER",
"OtherIdentifierState1": "CT",
"OtherIdentifierIssuer1": "HEALTH NET PROV ID",
"OtherIdentifier2": "511554",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "AETNA PROV ID",
"OtherIdentifier3": "001183920",
"OtherIdentifierType3": "MEDICAID",
"OtherIdentifierState3": "CT",
"OtherIdentifier4": "004215324",
"OtherIdentifierType4": "MEDICAID",
"OtherIdentifierState4": "CT",
"OtherIdentifier5": "01218392",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "CIGNA PROV ID",
"OtherIdentifier6": "132226",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "WELLCARE MEDICARE",
"OtherIdentifier7": "914792",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "HEALTH NET REF ID",
"OtherIdentifier8": "1255448155",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "GHMC GRP NPI ID",
"OtherIdentifier9": "050065",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "CONNECTICARE PROV ID",
"OtherIdentifier10": "010018392CT02",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "BCBS N BCFP PROV ID",
"OtherIdentifier11": "P369808",
"OtherIdentifierType11": "OTHER",
"OtherIdentifierState11": "CT",
"OtherIdentifierIssuer11": "OXFORD PROV ID",
"PrimaryTaxonomyCode": "207R00000X",
"PrimaryTaxonomy": "Internal Medicine Physician"
},
{
"NPI": "1639179476",
"EntityType": "Individual",
"IsSoleProprietor": "N",
"LastName": "MCDONALD",
"FirstName": "PATRICIA",
"MiddleName": "A",
"NamePrefix": "DR.",
"Credential": "M.D.",
"FirstLineMailingAddress": "210 MAIN ST PO BOX 38",
"MailingAddressCityName": "FARMINGTON",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06032-9992",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-539-9136",
"MailingAddressFaxNumber": "860-826-4436",
"FirstLinePracticeLocationAddress": "210 MAIN STREET PO BOX 38",
"PracticeLocationAddressCityName": "FARMINGTON",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06032-9992",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-539-9136",
"EnumerationDate": "07/22/2005",
"LastUpdateDate": "12/17/2024",
"GenderCode": "F",
"Gender": "Female",
"TaxonomyCode1": "207W00000X",
"Taxonomy1": "Ophthalmology Physician",
"LicenseNumber1": "024751",
"LicenseNumberStateCode1": "CT",
"PrimaryTaxonomySwitch1": "Y",
"OtherIdentifier1": "004214433",
"OtherIdentifierType1": "MEDICAID",
"OtherIdentifierState1": "CT",
"OtherIdentifier2": "1255448155",
"OtherIdentifierType2": "OTHER",
"OtherIdentifierState2": "CT",
"OtherIdentifierIssuer2": "GHMC GROUP NPI ID",
"OtherIdentifier3": "060065",
"OtherIdentifierType3": "OTHER",
"OtherIdentifierState3": "CT",
"OtherIdentifierIssuer3": "HEALTH NET",
"OtherIdentifier4": "481607",
"OtherIdentifierType4": "OTHER",
"OtherIdentifierState4": "CT",
"OtherIdentifierIssuer4": "AETNA",
"OtherIdentifier5": "P369883",
"OtherIdentifierType5": "OTHER",
"OtherIdentifierState5": "CT",
"OtherIdentifierIssuer5": "OXFORD",
"OtherIdentifier6": "010024751CT02",
"OtherIdentifierType6": "OTHER",
"OtherIdentifierState6": "CT",
"OtherIdentifierIssuer6": "BCBS & BCFP ID",
"OtherIdentifier7": "01024751",
"OtherIdentifierType7": "OTHER",
"OtherIdentifierState7": "CT",
"OtherIdentifierIssuer7": "CIGNA",
"OtherIdentifier8": "138005",
"OtherIdentifierType8": "OTHER",
"OtherIdentifierState8": "CT",
"OtherIdentifierIssuer8": "WELLCARE MEDICARE",
"OtherIdentifier9": "180024412",
"OtherIdentifierType9": "OTHER",
"OtherIdentifierState9": "CT",
"OtherIdentifierIssuer9": "RAIL ROAD MEDICARE ID",
"OtherIdentifier10": "7939301",
"OtherIdentifierType10": "OTHER",
"OtherIdentifierState10": "CT",
"OtherIdentifierIssuer10": "CONNECTICARE",
"CertificationDate": "12/17/2024",
"PrimaryTaxonomyCode": "207W00000X",
"PrimaryTaxonomy": "Ophthalmology Physician"
}
]
}