Provider Demographics
NPI:1164404117
Name:HARTFORD PHYSICIAN SERVICES PC
Entity type:Organization
Organization Name:HARTFORD PHYSICIAN SERVICES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:I
Authorized Official - Last Name:STAHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-571-7253
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:HARTFORD MEDICAL GROUP
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-7086
Mailing Address - Country:US
Mailing Address - Phone:508-595-0531
Mailing Address - Fax:508-829-5367
Practice Address - Street 1:200 RETREAT AVE
Practice Address - Street 2:8TH FLOOR- RESEARCH BLDG
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106
Practice Address - Country:US
Practice Address - Phone:860-545-7188
Practice Address - Fax:860-549-2215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT046916207T00000X
CT025147207RP1001X
CT48268207X00000X
207P00000X, 207Q00000X, 207QG0300X, 207RG0100X, 207RG0300X, 208000000X, 2083X0100X, 363A00000X, 363L00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004092904Medicaid
CA0228Medicare PIN
CTC00813Medicare PIN