Provider Demographics
NPI:1295860831
Name:WOODSTOCK MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:WOODSTOCK MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:KLARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-928-9270
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:168 RTE 171
Mailing Address - City:S WOODSTOCK
Mailing Address - State:CT
Mailing Address - Zip Code:06267-0366
Mailing Address - Country:US
Mailing Address - Phone:860-928-9270
Mailing Address - Fax:860-928-3852
Practice Address - Street 1:168 RTE 171
Practice Address - Street 2:
Practice Address - City:S WOODSTOCK
Practice Address - State:CT
Practice Address - Zip Code:06267-0366
Practice Address - Country:US
Practice Address - Phone:860-928-9270
Practice Address - Fax:860-928-3852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT50WOODSTKCT01OtherANTHEM BCBS GROUP NO.
CT50WOODSTKCT01OtherANTHEM BCBS GROUP NO.