Provider Demographics
NPI:1427035906
Name:GUANCO, BASILIO M (MD)
Entity Type:Individual
Prefix:DR
First Name:BASILIO
Middle Name:M
Last Name:GUANCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 NORTH MAIN STREET
Mailing Address - Street 2:HARTFORD MEDICAL GROUP PC
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042
Mailing Address - Country:US
Mailing Address - Phone:860-696-2300
Mailing Address - Fax:860-645-5352
Practice Address - Street 1:256 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040
Practice Address - Country:US
Practice Address - Phone:860-646-8595
Practice Address - Fax:860-645-3216
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT015050207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001150507Medicaid
060048751Medicare PIN
CT060000735Medicare ID - Type Unspecified
CT001150507Medicaid