Provider Demographics
NPI:1154340040
Name:COLLINS- BAINE, AMANDA C (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:C
Last Name:COLLINS- BAINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 OLD KINGS HWY N STE 205
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820-4735
Mailing Address - Country:US
Mailing Address - Phone:203-286-5604
Mailing Address - Fax:475-328-9072
Practice Address - Street 1:53 OLD KINGS HWY N STE 205
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820-4735
Practice Address - Country:US
Practice Address - Phone:203-286-5604
Practice Address - Fax:475-328-9072
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039661207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH39953Medicare UPIN
CTH39953Medicare UPIN
CT001396614Medicaid