Provider Demographics
NPI:1295976397
Name:CT.GASTROENTEROLOGY ASSOC. PC
Entity type:Organization
Organization Name:CT.GASTROENTEROLOGY ASSOC. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:POLIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-522-1171
Mailing Address - Street 1:1000 ASYLUM AVE
Mailing Address - Street 2:SUITE 3212
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1770
Mailing Address - Country:US
Mailing Address - Phone:860-522-1171
Mailing Address - Fax:860-493-6524
Practice Address - Street 1:1000 ASYLUM AVE
Practice Address - Street 2:SUITE 3212
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1770
Practice Address - Country:US
Practice Address - Phone:860-522-1171
Practice Address - Fax:860-493-6524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001824163WX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WX0106XNursing Service ProvidersRegistered NurseOccupational HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004221941Medicaid