Provider Demographics
NPI:1447337050
Name:OB-GYN ASSOCIATES OF WEST HARTFORD, PC
Entity type:Organization
Organization Name:OB-GYN ASSOCIATES OF WEST HARTFORD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-233-8589
Mailing Address - Street 1:1 NORTHWESTERN DR STE 202
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3400
Mailing Address - Country:US
Mailing Address - Phone:860-233-8589
Mailing Address - Fax:860-236-9636
Practice Address - Street 1:1 NORTHWESTERN DR STE 202
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3400
Practice Address - Country:US
Practice Address - Phone:860-233-8589
Practice Address - Fax:860-236-9636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017368207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0029111OtherAETNA/US HEALTHCARE
CT001173681Medicaid
CT010017368CT01OtherBLUE SHIELD
160000533Medicare ID - Type Unspecified
CT010017368CT01OtherBLUE SHIELD