Basic Information
| Provider Information | |||||||||
| NPI: | 1710447222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VASSAR HEALTH QUEST MEDICAL PRACTICE OF CONNECTICUT INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1351 ROUTE 55 STE 200 | ||||||||
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| City: | LAGRANGEVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125405128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454759661 | ||||||||
| FaxNumber: | 8454759938 | ||||||||
| Practice Location | |||||||||
| Address1: | 29 HOSPITAL HILL RD STE 1400 | ||||||||
| Address2: | |||||||||
| City: | SHARON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060692095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603647029 | ||||||||
| FaxNumber: | 8603647079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2019 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | LOOMIS | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 8454759661 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.