Basic Information
| Provider Information | |||||||||
| NPI: | 1104353481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIGGINS-CHEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CLARE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 COLUMBUS AVE | ||||||||
| Address2: | CREDENTIALING SPECIALIST | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033174 | ||||||||
| FaxNumber: | 2035033183 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 YORK ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036884242 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2017 | ||||||||
| LastUpdateDate: | 12/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 65025 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65025 | 01 | CT | STATE LICENSE | OTHER |