Individual Professional Information |
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NPI
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1205073962
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Unique healthcare provider (clinician) ID assigned by NPPES
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PECOS UID
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8628105210
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Unique individual clinician ID assigned by PECOS
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Professional Enrollment ID
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I20100430000472
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Unique ID for the individual professional enrollment that is the source for the data in the observation
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Provider Last Name
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JAQUEZ
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Individual professional last name
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Provider First Name
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COREY
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Individual professional first name
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Provider Middle Name
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A
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Individual professional middle name
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Provider Gender
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M
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The provider's gender if the provider is a person.
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Medical School Information |
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Medical School Name
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OTHER
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Individual professional's medical school
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Graduation Year
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2005
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Individual professional's medical school graduation year
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Primary Specialty
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FAMILY MEDICINE
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Primary medical specialty reported by the individual professional in the selected enrollment
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Secondary Specialty 1
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PERIPHERAL VASCULAR DISEASE
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First secondary medical specialty reported by the individual professional in the selected enrollment
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All Secondary Specialties
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PERIPHERAL VASCULAR DISEASE
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All four secondary specialties reported by the individual professional in the selected enrollment, separated by commas
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Practice Information |
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Organization Legal Name
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WEST HARTFORD MEDICAL CENTER
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Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
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Group Practice PAC ID
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4284764598
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Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
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Number of Group Practice members
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2
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Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
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Line 1 Street Address
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74 PARK RD
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Group Practice or individual's line 1 address
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City
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WEST HARTFORD
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Group Practice or individual's city
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State
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CT
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Group Practice or individual's state
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Zip Code
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061191853
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Group Practice or individual's zip code (9 digits when available)
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Phone Number
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8602181725
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Phone number is listed only when there is a single phone number available for the practice location address
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