Provider Demographics
NPI: | 1164404117 |
---|---|
Name: | HARTFORD PHYSICIAN SERVICES PC |
Entity Type: | Organization |
Organization Name: | HARTFORD PHYSICIAN SERVICES PC |
Other - Org Name: | HARTFORD MEDICAL GROUP |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | MD/MEDICAL DIRECTOR |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | KENT |
Authorized Official - Middle Name: | I |
Authorized Official - Last Name: | STAHL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 860-571-7253 |
Mailing Address - Street 1: | PO BOX 1086 |
Mailing Address - Street 2: | HARTFORD MEDICAL GROUP |
Mailing Address - City: | WILBRAHAM |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 01095-7086 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 508-595-0531 |
Mailing Address - Fax: | 508-829-5367 |
Practice Address - Street 1: | 200 RETREAT AVE |
Practice Address - Street 2: | 8TH FLOOR- RESEARCH BLDG |
Practice Address - City: | HARTFORD |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06106 |
Practice Address - Country: | US |
Practice Address - Phone: | 860-545-7188 |
Practice Address - Fax: | 860-549-2215 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-11-16 |
Last Update Date: | 2009-11-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
207P00000X, 207Q00000X, 207QG0300X, 207R00000X, 207RG0100X, 207RG0300X, 208000000X, 2083X0100X, 363A00000X, 363L00000X | ||
CT | 025147 | 207RP1001X |
CT | 046916 | 207T00000X |
CT | 48268 | 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207QG0300X | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2083X0100X | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CT | 004092904 | Medicaid | |
CA0228 | Medicare PIN | ||
CT | C00813 | Medicare PIN |