Basic Information
| Provider Information | |||||||||
| NPI: | 1073558508 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERIDEN-WALLINGFORD ANESTHESIA GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 744473 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303744473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1073558508 | ||||||||
| FaxNumber: | 9132426850 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 LEWIS AVE | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064512101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036948200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | KONDAS | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9548382371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 004000733 | 05 | CT | MEDICAID |