Basic Information
| Provider Information | |||||||||
| NPI: | 1093030975 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONWELL B. CARTER, M.D., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033250 | ||||||||
| FaxNumber: | 2035033254 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033250 | ||||||||
| FaxNumber: | 2035033254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2010 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | CONWELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3102766978 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | A23247 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 00A232470 | 05 | CA | MEDICAID | 004235900 | 05 | CT | MEDICAID |