Provider Demographics
NPI:1861584716
Name:HARBORPARK OBSTETRICS AND GYNECOLOGY, LLC
Entity type:Organization
Organization Name:HARBORPARK OBSTETRICS AND GYNECOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-852-0008
Mailing Address - Street 1:90 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3649
Mailing Address - Country:US
Mailing Address - Phone:860-852-0008
Mailing Address - Fax:860-852-0011
Practice Address - Street 1:90 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3649
Practice Address - Country:US
Practice Address - Phone:860-852-0008
Practice Address - Fax:860-852-0011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039292207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010039292CT04OtherANTHEM
039292OtherCONNECTICARE
CT001392927-02OtherBLUE CARE FAMILY PLAN
2V4200OtherHEALTHNET
CT3390202OtherAETNA
CT010039292CT04OtherANTHEM
CT3390202OtherAETNA
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