MEDICARE: OB-GYN ASSOCIATES OF WEST HARTFORD, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	017368	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0029111	OTHER	CT	AETNA/US HEALTHCARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	010017368CT01	OTHER	CT	BLUE SHIELD

General Provider Information

NPI Number	:	1447337050
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OB-GYN ASSOCIATES OF WEST HARTFORD, PC

Provider Business Mailing Address
First Line	:	1 NORTHWESTERN DR STE 202
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3400
Country	:	US
Telephone Number	:	860-233-8589
Fax Number	:	860-236-9636

Provider Business Practice Location Address
First Line	:	1 NORTHWESTERN DR STE 202
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3400
Country	:	US
Telephone Number	:	860-233-8589
Fax Number	:	860-236-9636

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MS. JACQUELYN GUSTAFSON
Credential	:
Telephone Number	:	860-233-8589

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	12/31/2020

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