Basic Information
| Provider Information | |||||||||
| NPI: | 1104955913 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YALE NEW HAVEN HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 DURHAM RD | ||||||||
| Address2: | |||||||||
| City: | GUILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064372058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034534734 | ||||||||
| FaxNumber: | 2033156728 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 YORK ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036889335 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | GALVIN | ||||||||
| AuthorizedOfficialFirstName: | MARY JANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FAMILY NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 2033157976 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | APRN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 000727 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | MGO741466 | 01 | CT | DEA | OTHER |