Provider Demographics
NPI:1790746337
Name:INTERNAL MEDICINE OF EAST HAVEN PC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE OF EAST HAVEN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:SHERARD
Authorized Official - Last Name:KASPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-468-9775
Mailing Address - Street 1:339 HEMINGWAY AVE
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512-2318
Mailing Address - Country:US
Mailing Address - Phone:203-468-9775
Mailing Address - Fax:
Practice Address - Street 1:339 HEMINGWAY AVE
Practice Address - Street 2:
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06512-2318
Practice Address - Country:US
Practice Address - Phone:203-468-9775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024717174400000X
CT024588174400000X
CT030998174400000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001309980Medicaid
CTB37949Medicare UPIN
CTF72051Medicare UPIN