NPIMap

Organization Active NPI

Mashantucket Pequot Tribal Council

  • Family Medicine Physician
  • Ledyard, CT
National Provider Identifier
1508140922
Registry record updated Sep 9, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
MASHANTUCKET PEQUOT TRIBAL COUNCIL
Practice address
75 Route 2
Ledyard, CT 06339-1128
Phone
(860) 312-8000
Fax
(860) 312-8001
NPI assigned
Oct 4, 2011
Last updated
Sep 9, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 9, 2014

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

Authorized official

Name
Shanna Tari Reels
Title
Tribal Health Services Director
Phone
(860) 312-8014

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

75 Route 2
Ledyard, CT 06339-1128

Mailing address

PO Box 3260
75 RT 2
Mashantucket, CT 06339-3260
Phone (860) 312-8000

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140818000464 TX Part B Supplier - Clinic/Group Practice 8628295599 Receives reassigned benefits from 5 practitioners
Practice locations: Ledyard, CT

National Provider Directory

National Provider Directory
Tax ID family
Mashantucket Pequot Tri5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

75 Route 2
Ledyard, CT 06339
Phone (860) 312-8000

Practitioners & affiliated clinicians

Practitioners 7

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.

NPI Registry JSON

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

{
    "created_epoch": "1317686400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1410220800000",
    "number": "1508140922",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3260",
            "address_2": "75 RT 2",
            "city": "MASHANTUCKET",
            "state": "CT",
            "postal_code": "063393260",
            "telephone_number": "860-312-8000",
            "fax_number": "860-312-8001"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "75 ROUTE 2",
            "city": "LEDYARD",
            "state": "CT",
            "postal_code": "063391128",
            "telephone_number": "860-312-8000",
            "fax_number": "860-312-8001"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MASHANTUCKET PEQUOT TRIBAL COUNCIL",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-10-04",
        "last_updated": "2014-09-09",
        "status": "A",
        "authorized_official_last_name": "REELS",
        "authorized_official_first_name": "SHANNA",
        "authorized_official_middle_name": "TARI",
        "authorized_official_title_or_position": "TRIBAL HEALTH SERVICES DIRECTOR",
        "authorized_official_telephone_number": "860-312-8014"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Ledyard, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 9, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.