Basic Information
| Provider Information | |||||||||
| NPI: | 1437132230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NATHANSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | HARRIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 YORK ST | ||||||||
| Address2: | LMP - 180 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037854138 | ||||||||
| FaxNumber: | 2037371345 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 YORK ST | ||||||||
| Address2: | LMP - 180 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037854138 | ||||||||
| FaxNumber: | 2037371345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2005 | ||||||||
| LastUpdateDate: | 11/14/2012 | ||||||||
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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 | 207RG0100X | 029365 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 001293654 | 05 | CT | MEDICAID |