PROSPECT CT MEDICAL FOUNDATION, INC.

Provider Demographics

• NPI: 1144677568
• Name: PROSPECT CT MEDICAL FOUNDATION, INC.
• Entity type: Organization
• Organization Name: PROSPECT CT MEDICAL FOUNDATION, INC.
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: SECRETARY
• Authorized Official - First Name: ROBERT
• Authorized Official - Middle Name: JON
• Authorized Official - Last Name: ELDERS
• Authorized Official - Phone: 714-788-1249
• Mailing Address - Street 1: 71 HAYNES ST
• Mailing Address - Street 2: MILLER BLDG., FLOOR G
• Mailing Address - City: MANCHESTER
• Mailing Address - State: CT
• Mailing Address - Zip Code: 06040-4131
• Mailing Address - Country: US
• Mailing Address - Phone: 860-533-2981
• Mailing Address - Fax: 860-533-2975
• Practice Address - Street 1: 71 HAYNES ST
• Practice Address - Street 2: MILLER BLDG., FLOOR G
• Practice Address - City: MANCHESTER
• Practice Address - State: CT
• Practice Address - Zip Code: 06040-4131
• Practice Address - Country: US
• Practice Address - Phone: 860-533-2981
• Practice Address - Fax: 860-533-2975
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2016-05-16
• Last Update Date: 2021-03-15

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	1041C0700X	Behavioral Health & Social Service Providers	Social Worker	Clinical	Group - Multi-Specialty
No	106H00000X	Behavioral Health & Social Service Providers	Marriage & Family Therapist		Group - Multi-Specialty
No	163W00000X	Nursing Service Providers	Registered Nurse		Group - Multi-Specialty
No	207R00000X	Allopathic & Osteopathic Physicians	Internal Medicine		Group - Multi-Specialty
No	207RE0101X	Allopathic & Osteopathic Physicians	Internal Medicine	Endocrinology, Diabetes & Metabolism	Group - Multi-Specialty
No	207RG0100X	Allopathic & Osteopathic Physicians	Internal Medicine	Gastroenterology	Group - Multi-Specialty
No	207VX0201X	Allopathic & Osteopathic Physicians	Obstetrics & Gynecology	Gynecologic Oncology	Group - Multi-Specialty
No	207X00000X	Allopathic & Osteopathic Physicians	Orthopaedic Surgery		Group - Multi-Specialty
No	208600000X	Allopathic & Osteopathic Physicians	Surgery		Group - Multi-Specialty
No	2086S0129X	Allopathic & Osteopathic Physicians	Surgery	Vascular Surgery	Group - Multi-Specialty
No	208G00000X	Allopathic & Osteopathic Physicians	Thoracic Surgery (Cardiothoracic Vascular Surgery)		Group - Multi-Specialty
No	208M00000X	Allopathic & Osteopathic Physicians	Hospitalist		Group - Multi-Specialty
No	363AM0700X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant	Medical	Group - Multi-Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty