Provider Demographics
NPI:1194817460
Name:MODERN ERA PEDIATRIC PRACTICE
Entity Type:Organization
Organization Name:MODERN ERA PEDIATRIC PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANSELM
Authorized Official - Middle Name:CHIBUIKE
Authorized Official - Last Name:ANYOHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-371-4800
Mailing Address - Street 1:3715 MAIN ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-3618
Mailing Address - Country:US
Mailing Address - Phone:203-371-4800
Mailing Address - Fax:203-371-4900
Practice Address - Street 1:3715 MAIN ST
Practice Address - Street 2:SUITE 403
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-3618
Practice Address - Country:US
Practice Address - Phone:203-371-4800
Practice Address - Fax:203-371-4900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001352799Medicaid
G44659Medicare UPIN
CT001352799Medicaid