Healthcare Provider Details

I. General information

NPI: 1295367068
Provider Name (Legal Business Name): HARTFORD HEALTHCARE MEDICAL GROUP SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 POHEGANUT DRIVE SUITE 3
GROTON CT
06340-3252
US

IV. Provider business mailing address

1290 SILAS DEANE HWY HHC CVO
WETHERSFIELD CT
06109
US

V. Phone/Fax

Practice location:
  • Phone: 860-437-3737
  • Fax:
Mailing address:
  • Phone: 860-972-9033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MARK BANCROFT VYE
Title or Position: VP OF ADMINISTRATION
Credential:
Phone: 860-972-7858