Provider Demographics
NPI:1033103130
Name:LANE-RETICKER, ALISON (MD)
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:
Last Name:LANE-RETICKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 415933
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5933
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR STREET
Practice Address - Street 2:HARTFORD HOSPITAL MEDICINE DEPT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-5037
Practice Address - Country:US
Practice Address - Phone:860-545-2876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018012207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001180124Medicaid
CT1033103130Medicaid
CT110010483Medicare PIN
E80496Medicare UPIN
CT001180124Medicaid