Healthcare Provider Details

I. General information

NPI: 1043368038
Provider Name (Legal Business Name): GLASTONBURY PODIATRY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEBRON AVE SUITE 211
GLASTONBURY CT
06033-2176
US

IV. Provider business mailing address

162 MANSFIELD AVE # A
WILLIMANTIC CT
06226-2041
US

V. Phone/Fax

Practice location:
  • Phone: 860-657-3668
  • Fax: 860-657-1678
Mailing address:
  • Phone: 860-456-4250
  • Fax: 860-456-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL JAMES SCANLON
Title or Position: OWNER
Credential: DPM
Phone: 860-456-4250