Provider Demographics
NPI:1467727495
Name:ANDREW GANELES MD LLC
Entity Type:Organization
Organization Name:ANDREW GANELES MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:GANELES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-651-1166
Mailing Address - Street 1:381 HOPMEADOW ST
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:WEATOGUE
Mailing Address - State:CT
Mailing Address - Zip Code:06089-9692
Mailing Address - Country:US
Mailing Address - Phone:860-651-1166
Mailing Address - Fax:860-651-1167
Practice Address - Street 1:381 HOPMEADOW ST
Practice Address - Street 2:SUITE 101B
Practice Address - City:WEATOGUE
Practice Address - State:CT
Practice Address - Zip Code:06089-9692
Practice Address - Country:US
Practice Address - Phone:860-651-1166
Practice Address - Fax:860-651-1167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035611261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
G77966Medicare UPIN