Provider Demographics
NPI:1356945182
Name:HARTFORD HEALTHCARE MEDICAL GROUP SPECIALISTS, LLC
Entity type:Organization
Organization Name:HARTFORD HEALTHCARE MEDICAL GROUP SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:BANCROFT
Authorized Official - Last Name:VYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-972-7858
Mailing Address - Street 1:1290 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4337
Mailing Address - Country:US
Mailing Address - Phone:680-972-9033
Mailing Address - Fax:860-972-7040
Practice Address - Street 1:2979 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4284
Practice Address - Country:US
Practice Address - Phone:203-382-2100
Practice Address - Fax:203-382-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty