Provider Demographics
NPI: | 1932138138 |
---|---|
Name: | SAINT RAPHAEL FACULTY PHYSICIANS |
Entity Type: | Organization |
Organization Name: | SAINT RAPHAEL FACULTY PHYSICIANS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CHIEF FINANCIAL OFFICER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | LAWRENCE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MCMANUS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 203-789-4059 |
Mailing Address - Street 1: | PO BOX 1951 |
Mailing Address - Street 2: | |
Mailing Address - City: | BRATTLEBORO |
Mailing Address - State: | VT |
Mailing Address - Zip Code: | 05302-1951 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 508-595-0531 |
Mailing Address - Fax: | 508-829-5367 |
Practice Address - Street 1: | 1450 CHAPEL ST |
Practice Address - Street 2: | |
Practice Address - City: | NEW HAVEN |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06511-4405 |
Practice Address - Country: | US |
Practice Address - Phone: | 203-789-5946 |
Practice Address - Fax: | 203-867-5287 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-07-01 |
Last Update Date: | 2013-04-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 1223S0112X | Dental Providers | Dentist | Oral and Maxillofacial Surgery | Group - Multi-Specialty |
No | 204E00000X | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 2080N0001X | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | Group - Multi-Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CT | 008002476 | Medicaid | |
CT | 008002619 | Medicaid | |
CT | 008003155 | Medicaid | |
CT | 008002615 | Medicaid | |
CT | 008002212 | Medicaid | |
CT | 008002476 | Medicaid | |
CT | C03552 | Medicare PIN |