Provider Demographics
NPI:1710172747
Name:ARDOLINO SALLY A
Entity Type:Organization
Organization Name:ARDOLINO SALLY A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ARDOLINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-586-7825
Mailing Address - Street 1:1007 FARMINGTON AVENUE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107
Mailing Address - Country:US
Mailing Address - Phone:860-586-7825
Mailing Address - Fax:860-586-7827
Practice Address - Street 1:1007 FARMINGTON AVENUE
Practice Address - Street 2:SUITE 9
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107
Practice Address - Country:US
Practice Address - Phone:860-586-7825
Practice Address - Fax:860-586-7827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026360207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB83440Medicare UPIN
CTC02173Medicare PIN