Basic Information
| Provider Information | |||||||||
| NPI: | 1386085850 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BURGDORF BANK OF AMERICA HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 131 COVENTRY ST | ||||||||
| Address2: | 2ND FLOOR ADMINISTRATION | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061121548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607142813 | ||||||||
| FaxNumber: | 8607148541 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 COVENTRY ST | ||||||||
| Address2: | 2ND FLOOR ADMINISTRATION | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061121548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607142813 | ||||||||
| FaxNumber: | 8607148541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2013 | ||||||||
| LastUpdateDate: | 07/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | GOULD | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SITE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8607143690 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINT FRANCIS HOSPITAL & MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.