Basic Information
| Provider Information | |||||||||
| NPI: | 1255752945 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AFC PHYSICIAN OF CONNECTICUT, PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609866440 | ||||||||
| FaxNumber: | 8609866439 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609866440 | ||||||||
| FaxNumber: | 2038262139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2013 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8609866440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QU0200X | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.