Provider Demographics
NPI:1881781029
Name:GREENWICH MEDICAL GROUP
Entity type:Organization
Organization Name:GREENWICH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:M
Authorized Official - Last Name:FENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-869-6960
Mailing Address - Street 1:75 HOLLY HILL LN
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6098
Mailing Address - Country:US
Mailing Address - Phone:203-869-6960
Mailing Address - Fax:203-869-5103
Practice Address - Street 1:75 HOLLY HILL LN
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6098
Practice Address - Country:US
Practice Address - Phone:203-869-6960
Practice Address - Fax:203-869-5103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTAS8735308207R00000X
CTBL9582493207R00000X
CTAA2470348207R00000X
CTBF4323503207R00000X
CTBV5838959207R00000X
CTBN3275369207RC0000X
CTAM6000715207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00439394RMedicaid
CT00439394RMedicaid