Provider Demographics
NPI:1760714661
Name:INTEGRATED MEDICAL OF NEW HAVEN, LLC
Entity Type:Organization
Organization Name:INTEGRATED MEDICAL OF NEW HAVEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:GERSTENFELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-773-1935
Mailing Address - Street 1:111 PARK ST
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5412
Mailing Address - Country:US
Mailing Address - Phone:203-773-1935
Mailing Address - Fax:203-773-0039
Practice Address - Street 1:111 PARK ST
Practice Address - Street 2:SUITE 1C
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5412
Practice Address - Country:US
Practice Address - Phone:203-773-1935
Practice Address - Fax:203-773-0039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031959207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF36301Medicare UPIN