Provider Demographics
NPI:1497866107
Name:MCKIERNAN, EDWARD G IV (RPT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:G
Last Name:MCKIERNAN
Suffix:IV
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 TECHNOLOGY DR
Mailing Address - Street 2:STE A200
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-6338
Mailing Address - Country:US
Mailing Address - Phone:203-268-5801
Mailing Address - Fax:203-452-3688
Practice Address - Street 1:115 TECHNOLOGY DR
Practice Address - Street 2:STE A200
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-6338
Practice Address - Country:US
Practice Address - Phone:203-268-5801
Practice Address - Fax:203-452-3688
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3918034OtherAETNA PIN
CT2V5288OtherHEALTH NET PIN
CT3515548OtherCIGNA PIN
CTA2983697OtherOXFORD PIN
CT080004917CT04OtherANTHEM BCBS PIN
CT3515548OtherCIGNA PIN
CTA2983697OtherOXFORD PIN