Provider Demographics
NPI:1821270513
Name:KENNETH F. MARICI, MD, PC
Entity Type:Organization
Organization Name:KENNETH F. MARICI, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:F
Authorized Official - Last Name:MARICI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-354-5511
Mailing Address - Street 1:11 PROSPECT HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-3732
Mailing Address - Country:US
Mailing Address - Phone:860-354-5511
Mailing Address - Fax:860-350-3122
Practice Address - Street 1:11 GROVE ST
Practice Address - Street 2:BOOTH HOUSE
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-3626
Practice Address - Country:US
Practice Address - Phone:860-354-5511
Practice Address - Fax:860-350-3122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036520207R00000X
CT001512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001365205Medicaid
CTC03850Medicare PIN