Provider Demographics
NPI:1164768255
Name:HARTFORD HEALTHCARE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:HARTFORD HEALTHCARE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:BANCROFT
Authorized Official - Last Name:VYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-972-7858
Mailing Address - Street 1:1290 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4337
Mailing Address - Country:US
Mailing Address - Phone:860-972-7040
Mailing Address - Fax:
Practice Address - Street 1:100 HAZARD AVE
Practice Address - Street 2:STE. 206
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-5446
Practice Address - Country:US
Practice Address - Phone:860-749-6252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment