Basic Information
| Provider Information | |||||||||
| NPI: | 1023120326 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTROENTEROLOGY CENTER OF CONNECTICUT, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 WHITNEY AVE | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065183691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032814463 | ||||||||
| FaxNumber: | 2032872914 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 WHITNEY AVE | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065183691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032814463 | ||||||||
| FaxNumber: | 2032872914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 05/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | JAFFE | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2032814463 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 040315 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 4180626 | 05 | CT | MEDICAID |