Basic Information
| Provider Information | |||||||||
| NPI: | 1922125673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALVIN | ||||||||
| FirstName: | J. (JOHN) | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | JR. M.D. M.P.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 415933 | ||||||||
| Address2: | HARTFORD HOSPITAL PROFESSIONAL SERVICES | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605457602 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 80 SEYMOUR STREET | ||||||||
| Address2: | HARTFORD HOSPITAL MEDICINE DEPT | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061025037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605450200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 12704 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine | 2083A0100X | 12704 | CT | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Aerospace Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001127042 | 05 | CT | MEDICAID |