Provider Demographics
NPI:1285837401
Name:NEW HAVEN WALK IN MEDICAL CENTER
Entity Type:Organization
Organization Name:NEW HAVEN WALK IN MEDICAL CENTER
Other - Org Name:NEW HAVEN WALK IN MEDICAL CENTER LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MALLICK
Authorized Official - Middle Name:QAISER
Authorized Official - Last Name:ALAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-562-8697
Mailing Address - Street 1:77 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-3906
Mailing Address - Country:US
Mailing Address - Phone:203-562-8697
Mailing Address - Fax:203-562-1822
Practice Address - Street 1:77 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3906
Practice Address - Country:US
Practice Address - Phone:203-562-8697
Practice Address - Fax:203-562-1822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034112208000000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy