Basic Information
| Provider Information | |||||||||
| NPI: | 1568994713 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UCONN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 CABOT ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060532984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504914207 | ||||||||
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| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | UCONN | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060300001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794017 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2017 | ||||||||
| LastUpdateDate: | 03/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | LANE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8606794017 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.