Provider Demographics
NPI:1922114495
Name:FAMILY PRACTICE OF GREATER NEW HAVEN, LLC
Entity type:Organization
Organization Name:FAMILY PRACTICE OF GREATER NEW HAVEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANATOLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAYLOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-269-4200
Mailing Address - Street 1:850 N MAIN STREET EXT
Mailing Address - Street 2:BUILDING 2 SUITE 1B
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2400
Mailing Address - Country:US
Mailing Address - Phone:203-269-4200
Mailing Address - Fax:203-269-8800
Practice Address - Street 1:850 N MAIN STREET EXT
Practice Address - Street 2:BUILDING 2 SUITE 1B
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2400
Practice Address - Country:US
Practice Address - Phone:203-269-4200
Practice Address - Fax:203-269-8800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040951207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001409516Medicaid
CTH73639Medicare UPIN
CT110009967Medicare PIN