Provider Demographics
NPI:1013147602
Name:HAMDEN MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:HAMDEN MEDICAL GROUP, LLC
Other - Org Name:HAMDEN MEDICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARTH
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-248-8142
Mailing Address - Street 1:2340 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3511
Mailing Address - Country:US
Mailing Address - Phone:203-248-8142
Mailing Address - Fax:203-248-7764
Practice Address - Street 1:2340 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3511
Practice Address - Country:US
Practice Address - Phone:203-248-8142
Practice Address - Fax:203-248-7764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004215605Medicaid
CT0003949400OtherCT TAX ID