Basic Information
| Provider Information | |||||||||
| NPI: | 1659766483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACNEIL | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MACNEIL | ||||||||
| OtherFirstName: | JULIE | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 360 STATE ST APT 2021 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012317169 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 290 WESTERN BLVD | ||||||||
| Address2: | |||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060331236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883440007 | ||||||||
| FaxNumber: | 8606529277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2015 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | E-11029 | AR | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 62394 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 228937001 | 05 | AR | MEDICAID |