Basic Information
| Provider Information | |||||||||
| NPI: | 1417955923 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST HAVEN MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 687 CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065163774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039326481 | ||||||||
| FaxNumber: | 2039324051 | ||||||||
| Practice Location | |||||||||
| Address1: | 687 CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065163774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039326481 | ||||||||
| FaxNumber: | 2039324051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 01/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | WALALIYADDA | ||||||||
| AuthorizedOfficialFirstName: | ANURUDDHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2039326481 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 016797 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207R00000X | 016636 | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.