Provider Demographics
NPI:1659552768
Name:EAST HARTFORD FAMILY PRACTICE LLP
Entity Type:Organization
Organization Name:EAST HARTFORD FAMILY PRACTICE LLP
Other - Org Name:EAST HARTFORD FAMILY PRACTICE LLP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DANYLIW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-569-4430
Mailing Address - Street 1:110 MAIN ST
Mailing Address - Street 2:1ST FL
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-3208
Mailing Address - Country:US
Mailing Address - Phone:860-569-4430
Mailing Address - Fax:860-569-4431
Practice Address - Street 1:110 MAIN ST
Practice Address - Street 2:1ST FL
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-3208
Practice Address - Country:US
Practice Address - Phone:860-569-4430
Practice Address - Fax:860-569-4431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1058742Medicaid
CT1058742Medicaid