MEDICARE: RAYMOND CHARLES KAISER PA

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	363A00000X	Physician Assistant	000765	CT
2	363AM0700X	Medical Physician Assistant	000765	CT

General Provider Information

NPI Number	:	1871579318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYMOND CHARLES KAISER PA

Provider Business Mailing Address
First Line	:	PO BOX 1086
Second Line	:	HARTFORD MEDICAL GROUP
City	:	WILBRAHAM
State	:	MA
Zip	:	01095-7086
Country	:	US
Telephone Number	:	508-595-0531
Fax Number	:	508-829-5367

Provider Business Practice Location Address
First Line	:	256 N MAIN ST
Second Line	:
City	:	MANCHESTER
State	:	CT
Zip	:	06042-2004
Country	:	US
Telephone Number	:	860-646-8595
Fax Number	:	860-645-3216

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	04/11/2012

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Directions to “ RAYMOND CHARLES KAISER PA” Practice Location

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