=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730361627
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARTFORD OPHTHALMOLOGY ASSOCIATES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2007
-----------------------------------------------------
Last Update Date | 12/03/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 WOODLAND ST SUITE 44
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06105-2372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-247-2169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 WOODLAND ST SUITE 44
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06105-2372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-247-2169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. EDMUND THADDEUS SUSKI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 860-247-2169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 22090
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------