Basic Information
| Provider Information | |||||||||
| NPI: | 1184834418 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | G. WALSH & M. COLLITON MD'S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 WOODLAND ST | ||||||||
| Address2: | SUITE 45 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061052372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605271669 | ||||||||
| FaxNumber: | 8602930783 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 WOODLAND ST | ||||||||
| Address2: | SUITE 45 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061052372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605271669 | ||||||||
| FaxNumber: | 8602930783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 11/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | WALSH | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8605271669 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 021042 | 01 | CT | LICENSE | OTHER | 1063496883 | 01 | NPI# | OTHER | 029475 | 01 | CT | LICENSE | OTHER | 1609853126 | 01 | NPI # | OTHER |