Healthcare Provider Details

I. General information

NPI: 1154972248
Provider Name (Legal Business Name): GLASTONBURY VASCULAR ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 GLASTONBURY BLVD STE 202
GLASTONBURY CT
06033-4456
US

IV. Provider business mailing address

2001 BUTTERFIELD RD STE 300
DOWNERS GROVE IL
60515-1069
US

V. Phone/Fax

Practice location:
  • Phone: 860-652-8400
  • Fax: 860-652-8401
Mailing address:
  • Phone: 630-725-2700
  • Fax: 833-842-5469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LORENA ESPARZA
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 630-725-2764