Basic Information
Provider Information | |||||||||
NPI: | 1811966997 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLINS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 263 FARMINGTON AVE | ||||||||
Address2: | PROVIDER ENROLLMENT | ||||||||
City: | FARMINGTON | ||||||||
State: | CT | ||||||||
PostalCode: | 060302212 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606794477 | ||||||||
FaxNumber: | 8606794474 | ||||||||
Practice Location | |||||||||
Address1: | 800 CONNECTICUT BLVD | ||||||||
Address2: | INTERNAL MEDICINE | ||||||||
City: | EAST HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061087303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8602823894 | ||||||||
FaxNumber: | 8602828582 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2006 | ||||||||
LastUpdateDate: | 02/16/2016 | ||||||||
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 | 207R00000X | 028808 | CT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1811966997 | 05 | CT |   | MEDICAID | 7702017 | 01 | CT | AETNA | OTHER | P3925929 | 01 | CT | OXFORD | OTHER | 2997745 | 01 | CT | CIGNA HEALTH CARE | OTHER | 028808 | 01 | CT | CONNECTICARE | OTHER | 010028808CT05 | 01 | CT | ANTHEM BC/BS | OTHER |