Provider Demographics
NPI:1598748451
Name:FLAHERTY-HEWITT, MARYELLEN BRIDGET (MD)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:BRIDGET
Last Name:FLAHERTY-HEWITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9805
Mailing Address - Street 2:300 GEORGE ST 6TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:203-785-7998
Mailing Address - Fax:203-785-6414
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:YALE PHYSICIANS BLDG
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-785-2140
Practice Address - Fax:203-785-6414
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040155208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001404554Medicaid
CT001404554Medicaid
J71899Medicare UPIN
CT370001706Medicare PIN