Provider Demographics
NPI:1225235757
Name:WINDHAM UROLOGY GROUP PC
Entity Type:Organization
Organization Name:WINDHAM UROLOGY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:N
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-423-5656
Mailing Address - Street 1:63 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:CT
Mailing Address - Zip Code:06234-1901
Mailing Address - Country:US
Mailing Address - Phone:860-412-0491
Mailing Address - Fax:860-412-0496
Practice Address - Street 1:63 CANTERBURY RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:CT
Practice Address - Zip Code:06234-1901
Practice Address - Country:US
Practice Address - Phone:860-412-0491
Practice Address - Fax:860-412-0496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C01328Medicare PIN