=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699212704
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GCNT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2017
-----------------------------------------------------
Last Update Date | 01/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 171 GRANDVIEW AVE STE 105
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-755-2214
-----------------------------------------------------
Fax | 203-596-1133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 171 GRANDVIEW AVE STE 105
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-755-2214
-----------------------------------------------------
Fax | 203-596-1133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MBR
-----------------------------------------------------
Name | GIAC-CHAN NGUYEN-TAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 203-848-7994
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PE0005X
-----------------------------------------------------
Taxonomy Name | Undersea and Hyperbaric Medicine (Emergency Medicine) Physician
-----------------------------------------------------
License Number | 028148
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 028148
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 028148
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------