Provider Demographics
NPI:1558436766
Name:THE GREENWICH MEDICAL GROUP
Entity Type:Organization
Organization Name:THE GREENWICH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-869-6960
Mailing Address - Street 1:75 HOLLY HILL LN
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6098
Mailing Address - Country:US
Mailing Address - Phone:203-869-6960
Mailing Address - Fax:
Practice Address - Street 1:75 HOLLY HILL LN
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6098
Practice Address - Country:US
Practice Address - Phone:203-869-6960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207R00000X, 207RC0000X, 207RP1001X
CT001163363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004393948Medicaid
CTC30447OtherRAILROAD MEDICARE GROUP #
CT471501OtherAETNA HMO GROUP NUMBER
CT8170815OtherAETNA PPO GROUP NUMBER
CT8170815OtherAETNA PPO GROUP NUMBER
CT=========OtherTAX ID NUMBER