Provider Demographics
NPI:1164456406
Name:SILVER LANE MEDICAL GROUP
Entity Type:Organization
Organization Name:SILVER LANE MEDICAL GROUP
Other - Org Name:SILVER LANE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SULTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:QURAISHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-568-7243
Mailing Address - Street 1:677 SILVER LN
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-1257
Mailing Address - Country:US
Mailing Address - Phone:860-568-7243
Mailing Address - Fax:860-895-8107
Practice Address - Street 1:677 SILVER LN
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-1257
Practice Address - Country:US
Practice Address - Phone:860-568-7243
Practice Address - Fax:860-895-8107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICAL CARE CENTER OF EAST HARTFORD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-11
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT=========OtherEIN