Provider Demographics
NPI:1700917523
Name:CONNECTICUT GASTROENTEROLOGY ASSOC PC
Entity Type:Organization
Organization Name:CONNECTICUT GASTROENTEROLOGY ASSOC PC
Other - Org Name:CONNECTICUT GASTROENTEROLOGY ASSOCIATES PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTENSKY
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
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:2007-03-07
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00203OtherMEDICARE GROUP NUMBER
CT004065934Medicaid