Healthcare Provider Details

I. General information

NPI: 1285624809
Provider Name (Legal Business Name): KEVIN J TALLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SEYMOUR ST SUITE 719
HARTFORD CT
06106-5501
US

IV. Provider business mailing address

305 WESTERN BLVD SUITE 100
GLASTONBURY CT
06033-4380
US

V. Phone/Fax

Practice location:
  • Phone: 860-522-0604
  • Fax: 860-522-1761
Mailing address:
  • Phone: 860-522-0604
  • Fax: 860-522-1761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number042086
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number042086
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: