Provider Demographics
NPI:1437504388
Name:MKILGANNONMD LLC
Entity Type:Organization
Organization Name:MKILGANNONMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KILGANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-283-2839
Mailing Address - Street 1:60 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:STORRS
Mailing Address - State:CT
Mailing Address - Zip Code:06268-2572
Mailing Address - Country:US
Mailing Address - Phone:860-283-2839
Mailing Address - Fax:860-283-9468
Practice Address - Street 1:14 CLUB RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:CT
Practice Address - Zip Code:06280-1000
Practice Address - Country:US
Practice Address - Phone:860-456-1107
Practice Address - Fax:860-283-9468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025777207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400081082Medicare PIN