Provider Demographics
NPI: | 1639286073 |
---|---|
Name: | GANESAN, MURUGESAPILLAI (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MURUGESAPILLAI |
Middle Name: | |
Last Name: | GANESAN |
Suffix: | |
Gender: | M |
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: | 680 BOSTON POST RD |
Mailing Address - Street 2: | |
Mailing Address - City: | MILFORD |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06460 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 203-878-8332 |
Mailing Address - Fax: | 203-876-0494 |
Practice Address - Street 1: | 680 BOSTON POST RD |
Practice Address - Street 2: | MEDICAL GROUP OF MILFORD |
Practice Address - City: | MILFORD |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06460-2686 |
Practice Address - Country: | US |
Practice Address - Phone: | 203-878-8332 |
Practice Address - Fax: | 203-876-0494 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-23 |
Last Update Date: | 2010-10-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CT | 17201 | 207R00000X, 207RP1001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
B84013 | Medicare UPIN | ||
110007302 | Medicare ID - Type Unspecified |