Provider Demographics
NPI:1295367068
Name:HARTFORD HEALTHCARE MEDICAL GROUP SPECIALISTS LLC
Entity Type:Organization
Organization Name:HARTFORD HEALTHCARE MEDICAL GROUP SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF 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:HHC CVO
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109
Mailing Address - Country:US
Mailing Address - Phone:860-972-9033
Mailing Address - Fax:
Practice Address - Street 1:85 POHEGANUT DRIVE
Practice Address - Street 2:SUITE 3
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3252
Practice Address - Country:US
Practice Address - Phone:860-437-3737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies