Basic Information
| Provider Information | |||||||||
| NPI: | 1518256452 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLLINS MEDICAL ASSOCIATES 2 PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 673 COTTAGE GROVE RD | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060023033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602423000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 ASYLUM AVE STE 3218 | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061051702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607145415 | ||||||||
| FaxNumber: | 8607148861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2011 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | BARRAK | ||||||||
| AuthorizedOfficialFirstName: | BECAHARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO- PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8607145415 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 018911 | CT | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001319880 | 05 | CT | MEDICAID |