Provider Demographics
NPI:1457688020
Name:INTERNAL MEDICINE OF GUILFORD LLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE OF GUILFORD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER OF LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EVANS
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-500-2080
Mailing Address - Street 1:96A BROAD ST
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2635
Mailing Address - Country:US
Mailing Address - Phone:203-453-3621
Mailing Address - Fax:855-736-5997
Practice Address - Street 1:96A BROAD ST
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2635
Practice Address - Country:US
Practice Address - Phone:203-453-3621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044810207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1184613705OtherNPI
CT044810OtherLICENSE NUMBER
CT1184613705OtherNPI
CT044810OtherLICENSE NUMBER