Provider Demographics
NPI:1750388260
Name:GREATER HARTFORD NEPHROLOGY, LLC
Entity type:Organization
Organization Name:GREATER HARTFORD NEPHROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:FORAN
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:860-769-9866
Mailing Address - Street 1:701 COTTAGE GROVE RD
Mailing Address - Street 2:SUITE B-220
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3080
Mailing Address - Country:US
Mailing Address - Phone:860-769-9866
Mailing Address - Fax:860-769-7300
Practice Address - Street 1:701 COTTAGE GROVE RD
Practice Address - Street 2:SUITE B-220
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3080
Practice Address - Country:US
Practice Address - Phone:860-769-9866
Practice Address - Fax:860-769-7300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4245959Medicaid
CTC03183Medicare ID - Type Unspecified