Basic Information
Provider Information | |||||||||
NPI: | 1134381122 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST HAVEN VA PODIATRIC SURGERY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CONNECTICUT HEALTHCARE CONSORTIUM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 90 GERRISH AVE | ||||||||
Address2: | APT 62 | ||||||||
City: | EAST HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 06512 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2672587344 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 950 CAMPBELL AVE | ||||||||
Address2: |   | ||||||||
City: | WEST HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 06516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2039325711 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2008 | ||||||||
LastUpdateDate: | 06/30/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GORECKI | ||||||||
AuthorizedOfficialFirstName: | GERALD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF PODIATRIC SURGERY | ||||||||
AuthorizedOfficialTelephone: | 2039325711 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 390200000X | CT | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.