Healthcare Provider Details

I. General information

NPI: 1558436766
Provider Name (Legal Business Name): THE GREENWICH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 HOLLY HILL LN
GREENWICH CT
06830-6098
US

IV. Provider business mailing address

75 HOLLY HILL LN
GREENWICH CT
06830-6098
US

V. Phone/Fax

Practice location:
  • Phone: 203-869-6960
  • Fax:
Mailing address:
  • Phone: 203-869-6960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001163
License Number StateCT

VIII. Authorized Official

Name: MR. STUART MCCALLEY
Title or Position: PRESIDENT
Credential: MD
Phone: 203-869-6960