Provider Demographics
NPI:1174513543
Name:SOUTHERN CONNECTICUT INTERNAL MEDICINE
Entity type:Organization
Organization Name:SOUTHERN CONNECTICUT INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-781-4444
Mailing Address - Street 1:150 SARGENT DR
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6110
Mailing Address - Country:US
Mailing Address - Phone:203-781-4444
Mailing Address - Fax:203-789-8341
Practice Address - Street 1:150 SARGENT DR
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6110
Practice Address - Country:US
Practice Address - Phone:203-781-4444
Practice Address - Fax:203-789-8341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004197986Medicaid
CT004197986Medicaid