Basic Information
| Provider Information | |||||||||
| NPI: | 1366439036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELWELL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 22 MASONIC AVE. | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036795900 | ||||||||
| FaxNumber: | 2036796873 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 MASONIC AVE. | ||||||||
| Address2: | 1ST FLR | ||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036795900 | ||||||||
| FaxNumber: | 2036796873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2005 | ||||||||
| LastUpdateDate: | 01/20/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21753 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1217538 | 05 | CT | MEDICAID | 4239676 | 01 | CT | AETNA | OTHER | 010021753CT01 | 01 | CT | ANTHEM BC OF CT | OTHER | 061043813002 | 01 | CT | CIGNA | OTHER | 021753 | 01 | CT | CONNECTICARE | OTHER | OR4598 | 01 | CT | HEALTH NET | OTHER | P400371 | 01 | CT | OXFORD | OTHER |