Healthcare Provider Details

I. General information

NPI: 1710397005
Provider Name (Legal Business Name): ANDREW GRAHAM RAISBECK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR ST
HARTFORD CT
06106-3315
US

IV. Provider business mailing address

2 TRAP FALLS RD STE 414
SHELTON CT
06484-7621
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number59984
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: