Provider Demographics
NPI:1457573933
Name:CONNECTICUT GERIATRIC SPECIALTY GROUP, PC
Entity Type:Organization
Organization Name:CONNECTICUT GERIATRIC SPECIALTY GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HOULE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-523-3895
Mailing Address - Street 1:1 ABRAHMS BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117
Mailing Address - Country:US
Mailing Address - Phone:860-523-3854
Mailing Address - Fax:860-523-3828
Practice Address - Street 1:1 ABRAHMS BOULEVARD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117
Practice Address - Country:US
Practice Address - Phone:860-523-3854
Practice Address - Fax:860-523-3828
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEBREW HOME & HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03907Medicare PIN