Provider Demographics
NPI:1841301561
Name:MCKIERNAN PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:MCKIERNAN PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCKIERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:203-268-5801
Mailing Address - Street 1:115 TECHNOLOGY DR
Mailing Address - Street 2:STE A-200
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-6337
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 A-200
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-6337
Practice Address - Country:US
Practice Address - Phone:203-268-5801
Practice Address - Fax:203-452-3688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004917332BC3200X, 335E00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V5288OtherHEALTH NET PIN
CT3917515OtherAETNA PIN
CT080004917CT04OtherANTHEM BCBS PIN
CT3515548OtherCIGNA PIN
CTA2983697OtherOXFORD PIN
CT3515548OtherCIGNA PIN
CTA2983697OtherOXFORD PIN