Provider Demographics
NPI:1043368038
Name:GLASTONBURY PODIATRY GROUP
Entity type:Organization
Organization Name:GLASTONBURY PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SCANLON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-456-4250
Mailing Address - Street 1:162 MANSFIELD AVE # A
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2041
Mailing Address - Country:US
Mailing Address - Phone:860-456-4250
Mailing Address - Fax:860-456-3745
Practice Address - Street 1:300 HEBRON AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2176
Practice Address - Country:US
Practice Address - Phone:860-657-3668
Practice Address - Fax:860-657-1678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTIN