Provider Demographics
NPI:1669674743
Name:CONNECTICUT GASTROENTEROLOGY CONSULTANTS, P.C.
Entity Type:Organization
Organization Name:CONNECTICUT GASTROENTEROLOGY CONSULTANTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:BENNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-777-0304
Mailing Address - Street 1:40 TEMPLE ST
Mailing Address - Street 2:SUITE 4A
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2715
Mailing Address - Country:US
Mailing Address - Phone:203-777-0304
Mailing Address - Fax:203-401-4687
Practice Address - Street 1:40 TEMPLE ST
Practice Address - Street 2:SUITE 4A
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2715
Practice Address - Country:US
Practice Address - Phone:203-777-0304
Practice Address - Fax:203-401-4687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004001541Medicaid
CT004001541Medicaid