Basic Information
| Provider Information | |||||||||
| NPI: | 1275785214 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL CARE CENTER OF EAST HARTFORD LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SILVER LANE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 677 SILVER LN | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061181257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605697399 | ||||||||
| FaxNumber: | 8608958107 | ||||||||
| Practice Location | |||||||||
| Address1: | 677 SILVER LN | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061181257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605697399 | ||||||||
| FaxNumber: | 8608958107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2008 | ||||||||
| LastUpdateDate: | 06/10/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | QURAISHI | ||||||||
| AuthorizedOfficialFirstName: | SULTAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/ OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8605697399 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 030076 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 208600000X | 030076 | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 010030076CT01 | 01 | CT | ANTHEM | OTHER | 0199717 | 01 | CT | CIGNA | OTHER | 061322559 | 01 | CT | UNICARE COMMONWEALTH | OTHER | P3788258 | 01 | CT | OXFORD HEALTH PLANS | OTHER | 00000898346 15 | 01 | CT | UNITED HEALTH CARE | OTHER | 004239168 | 05 | CT | MEDICAID | 2V7144 | 01 | CT | HEALTHNET | OTHER | 4245029 | 01 | CT | AETNA | OTHER | 206592 | 01 | CT | WELLCARE/PREFERRED ONE | OTHER |