Basic Information
| Provider Information | |||||||||
| NPI: | 1568938843 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANITAS OF CONNECTICUT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4551 MAIN ST | ||||||||
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| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066061818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443074827 | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 MAIN ST | ||||||||
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| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061061818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443074827 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2018 | ||||||||
| LastUpdateDate: | 10/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | DARSA | ||||||||
| AuthorizedOfficialFirstName: | ALBERTO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3054702948 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SANITAS OF CONNECTICUT LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.