Provider Demographics
NPI:1669623484
Name:WEST HAVEN MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:WEST HAVEN MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENEDICT
Authorized Official - Middle Name:L
Authorized Official - Last Name:FERNANDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-932-6481
Mailing Address - Street 1:687 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-3774
Mailing Address - Country:US
Mailing Address - Phone:203-932-6481
Mailing Address - Fax:203-932-4051
Practice Address - Street 1:687 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3774
Practice Address - Country:US
Practice Address - Phone:203-932-6481
Practice Address - Fax:203-932-4051
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST HAVEN MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004250833Medicaid
CT004250833Medicaid