Provider Demographics
NPI:1659371789
Name:ELY, MATTHEW GRISWOLD III (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GRISWOLD
Last Name:ELY
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 SEYMOUR ST
Mailing Address - Street 2:STE 416
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5501
Mailing Address - Country:US
Mailing Address - Phone:860-947-8500
Mailing Address - Fax:860-524-8643
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:STE 416
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-947-8500
Practice Address - Fax:860-524-8643
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT016178208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP2043630OtherOXFORD
CT076334OtherCONNECTICARE
MA3164896Medicaid
CT2053938OtherAETNA
CT4416097 001OtherCIGNA
CT0V4532OtherHEALTH NET
CT010016178CT01OtherANTHEM BC/BS
CT12077OtherHEALTH NEW ENGLAND
B39525Medicare UPIN