Basic Information
| Provider Information | |||||||||
| NPI: | 1689691768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTIN | ||||||||
| FirstName: | MIHAELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7365 MAIN ST | ||||||||
| Address2: | BRIDGEPORT ANESTHESIA ASSOCIATES, P.C. | ||||||||
| City: | STRATFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066141300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843174 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 267 GRANT ST | ||||||||
| Address2: | BRIDGEPORT ANESTHESIA ASSOCIATES, P.C. | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 10/27/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 1411214 | CT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 001411214P1 | 01 | CT | BLUE CARE FAMILY PLAN | OTHER | 050001413 | 01 | CT | MEDICARE PTAN | OTHER | 060855634 | 01 | CT | COMMUNITY HEALTH NETWORK | OTHER | 1411214 | 05 | CT | MEDICAID | 3666614 | 01 | CT | CIGNA CT | OTHER | 755634 | 01 | CT | CONNECTICARE | OTHER | 500HBA011CT01 | 01 | CT | BCBS CT | OTHER | P00134657 | 01 | CT | RAILROAD MEDICARE | OTHER |