Provider Demographics
NPI:1023120326
Name:GASTROENTEROLOGY CENTER OF CONNECTICUT, PC
Entity type:Organization
Organization Name:GASTROENTEROLOGY CENTER OF CONNECTICUT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:JAFFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-281-4463
Mailing Address - Street 1:2200 WHITNEY AVE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3691
Mailing Address - Country:US
Mailing Address - Phone:203-281-4463
Mailing Address - Fax:203-287-2914
Practice Address - Street 1:2200 WHITNEY AVE
Practice Address - Street 2:SUITE 360
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3691
Practice Address - Country:US
Practice Address - Phone:203-281-4463
Practice Address - Fax:203-287-2914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040315207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4180626Medicaid
CTC02216Medicare ID - Type Unspecified