NPIMap

Organization Active NPI

Back to Health of Branford, LLC

  • Internal Medicine Physician
  • Branford, CT
National Provider Identifier
1215958772
Registry record updated Dec 22, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
037255 Issued in CT
Legal business name
BACK TO HEALTH OF BRANFORD, LLC
Practice address
400 West Main Street
Branford, CT 06405
Phone
(203) 483-7778
Fax
(203) 481-0234
NPI assigned
Jul 21, 2006
Last updated
Dec 22, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 22, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Sharon L Bailey
Title
Office Administrator
Phone
(203) 483-7778

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X 037255 CT
Prosthetic/Orthotic Supplier 335E00000X 037255 CT
Family Nurse Practitioner 363LF0000X 002765 CT
Chiropractor 111N00000X 148 CT
Chiropractor 111N00000X 001614 CT
Internist Chiropractor 111NI0900X 000561 CT
Internal Medicine Physician 207R00000X 037255 CT Primary

Addresses

Primary practice location

400 West Main Street
Branford, CT 06405

Mailing address

400 W Main St
Branford, CT 06405-3416
Phone (203) 483-7778

Other identifiers 4

IdentifierTypeStateIssuer
008038939MedicaidCT
07D1072612OtherCTCLIA WAIVER
008038901MedicaidCT
C02868OtherGROUP

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040908001006 CT Part B Supplier - Clinic/Group Practice 9739155045 Receives reassigned benefits from 6 practitioners
Practice locations: Branford, CT

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
07D1072612Back to Health of Branford LLC400 West Main Street, Branford, CT 06405Certificate of waiverAug 20, 2027

National Provider Directory

National Provider Directory

Locations

400 W Main St
Branford, CT 06405
Phone (203) 483-7778

Practitioners & affiliated clinicians

Practitioners 23

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 23

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153440000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1419206400000",
    "number": "1215958772",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "400 W MAIN ST",
            "city": "BRANFORD",
            "state": "CT",
            "postal_code": "064053416",
            "telephone_number": "203-483-7778",
            "fax_number": "203-481-0234"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 WEST MAIN STREET",
            "city": "BRANFORD",
            "state": "CT",
            "postal_code": "06405",
            "telephone_number": "203-483-7778",
            "fax_number": "203-481-0234"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BACK TO HEALTH OF BRANFORD, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-21",
        "last_updated": "2014-12-22",
        "status": "A",
        "authorized_official_last_name": "BAILEY",
        "authorized_official_first_name": "SHARON",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "OFFICE ADMINISTRATOR",
        "authorized_official_telephone_number": "203-483-7778"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "CT",
            "license": "037255",
            "primary": false
        },
        {
            "code": "335E00000X",
            "taxonomy_group": "",
            "desc": "Prosthetic/Orthotic Supplier",
            "state": "CT",
            "license": "037255",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "CT",
            "license": "002765",
            "primary": false
        },
        {
            "code": "111N00000X",
            "taxonomy_group": "",
            "desc": "Chiropractor",
            "state": "CT",
            "license": "148",
            "primary": false
        },
        {
            "code": "111N00000X",
            "taxonomy_group": "",
            "desc": "Chiropractor",
            "state": "CT",
            "license": "001614",
            "primary": false
        },
        {
            "code": "111NI0900X",
            "taxonomy_group": "",
            "desc": "Chiropractor, Internist",
            "state": "CT",
            "license": "000561",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "CT",
            "license": "037255",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "008038939",
            "state": "CT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA WAIVER",
            "identifier": "07D1072612",
            "state": "CT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "008038901",
            "state": "CT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP",
            "identifier": "C02868",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Branford, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.