=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467727495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREW GANELES MD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2012
-----------------------------------------------------
Last Update Date | 03/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 381 HOPMEADOW ST SUITE 101B
-----------------------------------------------------
City | WEATOGUE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06089-9692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-651-1166
-----------------------------------------------------
Fax | 860-651-1167
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 381 HOPMEADOW ST SUITE 101B
-----------------------------------------------------
City | WEATOGUE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06089-9692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-651-1166
-----------------------------------------------------
Fax | 860-651-1167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PRACTITIONER
-----------------------------------------------------
Name | DR. ANDREW GANELES
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 860-651-1166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 035611
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------