Basic Information
| Provider Information | |||||||||
| NPI: | 1952548166 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 1700 DIXWELL HEALTHCARE GROUP, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FIRST CARE PHYSICAL MEDICINE & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 DIXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065143147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033972225 | ||||||||
| FaxNumber: | 2032889775 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 DIXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065143147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033972225 | ||||||||
| FaxNumber: | 2032889775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2009 | ||||||||
| LastUpdateDate: | 06/17/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARONE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2033896188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 000627 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.