Basic Information
| Provider Information | |||||||||
| NPI: | 1669674743 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONNECTICUT GASTROENTEROLOGY CONSULTANTS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 TEMPLE ST | ||||||||
| Address2: | SUITE 4A | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065102715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037770304 | ||||||||
| FaxNumber: | 2034014687 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 TEMPLE ST | ||||||||
| Address2: | SUITE 4A | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065102715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037770304 | ||||||||
| FaxNumber: | 2034014687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | BENNICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2037770304 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 004001541 | 05 | CT | MEDICAID |