Provider Demographics
NPI:1508981713
Name:EAR NOSE & THROAT SPECIALISTS OF CENTRAL CONNECTICUT P.C.
Entity Type:Organization
Organization Name:EAR NOSE & THROAT SPECIALISTS OF CENTRAL CONNECTICUT P.C.
Other - Org Name:DR. ROBERT A. GRYBOSKI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OTOLARYNGOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ANDRE
Authorized Official - Last Name:GRYBOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-225-7761
Mailing Address - Street 1:233 MAIN ST
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-4204
Mailing Address - Country:US
Mailing Address - Phone:860-225-7761
Mailing Address - Fax:860-225-6657
Practice Address - Street 1:233 MAIN ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-4204
Practice Address - Country:US
Practice Address - Phone:860-225-7761
Practice Address - Fax:860-225-6657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12647174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010012647CT01OtherBLUE CROSS BLUE SHIELD
CT04002630Medicaid
CT004190196Medicaid
CTHAS700OtherOXFORD
CT004105294Medicaid
CT010012647CT01OtherBLUE CARE FAMILY PLAN
CTOR4199OtherHEALTHNET
CT073071OtherCONNECTICARE
CT517950OtherAETNA
CTB37815Medicare UPIN
CT004105294Medicaid