MEDICARE: GREATER HARTFORD NEPHROLOGY, LLC

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	207RN0300X	Nephrology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750388260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER HARTFORD NEPHROLOGY, LLC

Provider Business Mailing Address
First Line	:	701 COTTAGE GROVE RD
Second Line	:	SUITE B-220
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3080
Country	:	US
Telephone Number	:	860-769-9866
Fax Number	:	860-769-7300

Provider Business Practice Location Address
First Line	:	701 COTTAGE GROVE RD
Second Line	:	SUITE B-220
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3080
Country	:	US
Telephone Number	:	860-769-9866
Fax Number	:	860-769-7300

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MS. NIKKI FORAN
Credential	:	BS
Telephone Number	:	860-769-9866

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	11/20/2012

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