Basic Information
| Provider Information | |||||||||
| NPI: | 1427035906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUANCO | ||||||||
| FirstName: | BASILIO | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 256 NORTH MAIN STREET | ||||||||
| Address2: | HARTFORD MEDICAL GROUP PC | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606962300 | ||||||||
| FaxNumber: | 8606455352 | ||||||||
| Practice Location | |||||||||
| Address1: | 256 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606468595 | ||||||||
| FaxNumber: | 8606453216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 10/11/2011 | ||||||||
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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 | 207R00000X | 015050 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001150507 | 05 | CT | MEDICAID |