Basic Information
| Provider Information | |||||||||
| NPI: | 1023124625 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONNECTICUT GI PC | ||||||||
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| OtherOrganizationName: | GI & INTERNAL MEDICINE ASSOC AND CONNECTICUT GASTROENTEROLOGY MEDICAL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 WATERCHASE DR | ||||||||
| Address2: | |||||||||
| City: | ROCKY HILL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060672110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602574131 | ||||||||
| FaxNumber: | 8602574519 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 SEYMOUR ST | ||||||||
| Address2: | 1000 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061065501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602462571 | ||||||||
| FaxNumber: | 8602463691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 11/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | CAPPA | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8602462277 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | P004137677 | 05 | CT | MEDICAID |