Provider Demographics
NPI:1245296730
Name:RICHARD MONTICCIOLO MD AND MARIE MONTICCIOLO MD LLP
Entity type:Organization
Organization Name:RICHARD MONTICCIOLO MD AND MARIE MONTICCIOLO MD LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:HUNAZANT
Authorized Official - Last Name:MONTICCIOLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-257-7405
Mailing Address - Street 1:2275 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067
Mailing Address - Country:US
Mailing Address - Phone:860-257-7405
Mailing Address - Fax:860-257-8788
Practice Address - Street 1:2275 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067
Practice Address - Country:US
Practice Address - Phone:860-257-7405
Practice Address - Fax:860-257-8788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2010-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030751207R00000X
CT028760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004163010Medicaid
CT004163010Medicaid