Basic Information
| Provider Information | |||||||||
| NPI: | 1417930629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAVAGE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LONG WHARF DR | ||||||||
| Address2: | STE321 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 LONG WHARF DR | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 034013 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0802X | 034013 | CT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084A0401X | 034013 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 008001325 | 05 | CT | MEDICAID | 004041000 | 05 | CT | MEDICAID | 004217099 | 05 | CT | MEDICAID | 008022622 | 05 | CT | MEDICAID | 008042339 | 05 | CT | MEDICAID | C01033 | 01 | CT | APT FOUNDATION PTAN | OTHER | 001340132 | 05 | CT | MEDICAID | 500000315 | 05 | CT | MEDICAID | 008039745 | 05 | CT | MEDICAID | 008024427 | 05 | CT | MEDICAID | 004082260 | 05 | CT | MEDICAID | 004082286 | 05 | CT | MEDICAID | 008003745 | 05 | CT | MEDICAID | 008022626 | 05 | CT | MEDICAID | 008023170 | 05 | CT | MEDICAID |