Provider Demographics
NPI:1174791420
Name:FAMILY PRACTICE AND INTERNAL MEDICINE OF HAMDEN
Entity type:Organization
Organization Name:FAMILY PRACTICE AND INTERNAL MEDICINE OF HAMDEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANKUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-288-6197
Mailing Address - Street 1:35 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-4028
Mailing Address - Country:US
Mailing Address - Phone:203-288-6197
Mailing Address - Fax:203-287-2842
Practice Address - Street 1:35 SCOTT ST
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-4028
Practice Address - Country:US
Practice Address - Phone:203-288-6197
Practice Address - Fax:203-287-2842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001304493Medicaid
CTC03933Medicare PIN