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General NPI Number Information
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NPI Number | 1457688020
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Entity Type | Organization
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Legal Business Name | INTERNAL MEDICINE OF GUILFORD LLC
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Dates
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Enumeration Date | 11/03/2009
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Last Update Date | 09/19/2019
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Provider Practice Location Address
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Address Line | 96A BROAD ST
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City | GUILFORD
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State | CT
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Zip | 06437-2635
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Country | US
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Telephone | 203-453-3621
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Fax |
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Provider Business Mailing Address
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Address Line | 96A BROAD ST
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City | GUILFORD
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State | CT
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Zip | 06437-2635
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Country | US
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Telephone | 203-453-3621
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Fax | 855-736-5997
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Authorized Official
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Title or Position | SINGLE MEMBER OF LLC
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Name | DR. CHARLES EVANS GLASS
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Credential | M.D.
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Telephone | 203-500-2080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 044810
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License Number State | CT
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