Provider Demographics
NPI:1881688034
Name:POLUKHIN, MARYANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYANNA
Middle Name:
Last Name:POLUKHIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARYANNA
Other - Middle Name:
Other - Last Name:GOZUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 KENSINGTON AVE
Mailing Address - Street 2:GROVE HILL MEDICAL CENTER
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-3916
Mailing Address - Country:US
Mailing Address - Phone:860-666-5252
Mailing Address - Fax:860-666-5153
Practice Address - Street 1:18 CEDAR ST
Practice Address - Street 2:GROVE HILL MEDICAL CENTER
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2647
Practice Address - Country:US
Practice Address - Phone:860-666-5252
Practice Address - Fax:860-666-5153
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034968207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001349689Medicaid
CT1255448155OtherGHMC GROUP NPI ID
CT5247130OtherAETNA
CTP369816OtherOXFORD
CT060118OtherHEALTH NET
CT110182439OtherRAIL ROAD MEDICARE
CT349680OtherCONNECTICARE
CT004215324Medicaid
CT010034968CT04OtherBCBS & BCFP PROV ID
CT01034968OtherCIGNA
CT001349689Medicaid
CT060118OtherHEALTH NET
CT110006011Medicare ID - Type Unspecified