Provider Demographics
NPI:1518098698
Name:STAFFORD MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:STAFFORD MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SULTAN
Authorized Official - Middle Name:ALAM
Authorized Official - Last Name:QURAISHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-558-3624
Mailing Address - Street 1:146 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071-1825
Mailing Address - Country:US
Mailing Address - Phone:860-749-8018
Mailing Address - Fax:860-316-4015
Practice Address - Street 1:146 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:CT
Practice Address - Zip Code:06071-1825
Practice Address - Country:US
Practice Address - Phone:860-749-8018
Practice Address - Fax:860-316-4015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT30076207Q00000X, 208600000X
CT5393363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT130076400OtherBLUE CARE FAMILY PLAN
CT010030076CT04OtherANTHEM
CT4245029OtherAETNA
CT5861484OtherCIGNA
CTHAS028OtherOXFORD
CT00000898346OtherUNITED HEALTHCARE
CT2V4565OtherHEALTHNET
CT217079Medicaid
CT781160OtherCONNECTICARE