Basic Information
| Provider Information | |||||||||
| NPI: | 1194859058 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GALES FERRY MEDICAL GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 335 | ||||||||
| Address2: | |||||||||
| City: | GALES FERRY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063350335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604647274 | ||||||||
| FaxNumber: | 8604647404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1527 ROUTE 12 | ||||||||
| Address2: | |||||||||
| City: | GALES FERRY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063351800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604647274 | ||||||||
| FaxNumber: | 8604647404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HENNESSEY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8604647253 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.