Basic Information
| Provider Information | |||||||||
| NPI: | 1902889835 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRIED | ||||||||
| FirstName: | TERRI | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065111936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037856610 | ||||||||
| FaxNumber: | 2037856414 | ||||||||
| Practice Location | |||||||||
| Address1: | 789 HOWARD AVE | ||||||||
| Address2: | DANA BUILDING - 3RD FLOOR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036886361 | ||||||||
| FaxNumber: | 2036884209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 034622 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 034622 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001346221 | 05 | CT | MEDICAID |