Healthcare Provider Details

I. General information

NPI: 1750388260
Provider Name (Legal Business Name): GREATER HARTFORD NEPHROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 COTTAGE GROVE RD SUITE B-220
BLOOMFIELD CT
06002-3080
US

IV. Provider business mailing address

701 COTTAGE GROVE RD SUITE B-220
BLOOMFIELD CT
06002-3080
US

V. Phone/Fax

Practice location:
  • Phone: 860-769-9866
  • Fax: 860-769-7300
Mailing address:
  • Phone: 860-769-9866
  • Fax: 860-769-7300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4245959
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name: MS. NIKKI FORAN
Title or Position: PRACTICE MANAGER
Credential: BS
Phone: 860-769-9866