Provider Demographics
NPI:1508065640
Name:ANTHONY D CIARDELLA M.D. PC
Entity Type:Organization
Organization Name:ANTHONY D CIARDELLA M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CIARDELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-621-6759
Mailing Address - Street 1:360-14 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489
Mailing Address - Country:US
Mailing Address - Phone:860-621-6759
Mailing Address - Fax:860-621-0117
Practice Address - Street 1:360-14 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489
Practice Address - Country:US
Practice Address - Phone:860-621-6759
Practice Address - Fax:860-621-0117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024620207R00000X
CT34236363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02732OtherMEDICARE GROUP #
CTC02732OtherMEDICARE GROUP #