Basic Information
Provider Information | |||||||||
NPI: | 1124013792 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHIMKIN | ||||||||
FirstName: | PETER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9135 | ||||||||
Address2: |   | ||||||||
City: | BROOKLINE | ||||||||
State: | MA | ||||||||
PostalCode: | 024469135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009270002 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 56 QUARRY RD | ||||||||
Address2: |   | ||||||||
City: | TRUMBULL | ||||||||
State: | CT | ||||||||
PostalCode: | 066114874 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2036966125 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2005 | ||||||||
LastUpdateDate: | 03/08/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 014936 | CT | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 001149368 | 05 | CT |   | MEDICAID | 300124895 | 01 | CT | RAILROAD MEDICARE | OTHER | 0086989 | 01 | CT | AETNA CT | OTHER | ANC1162 | 01 | CT | OXFORD HEALTH PLANS | OTHER | OV9113 | 01 | CT | HEALTH NET | OTHER | 500HBX051CT01 | 01 | CT | BCBS CT | OTHER | 061613357 | 01 | CT | CIGNA CT | OTHER | 2069098 | 01 | CT | UNITED HEALTHCARE | OTHER |