| West Hartford Medical Center | |
|
74 Park Rd Ste 4 West Hartford CT 06119-1898 | |
| (860) 218-1725 | |
| Not Available |
| Full Name | West Hartford Medical Center |
|---|---|
| Speciality | Family Medicine |
| Location | 74 Park Rd Ste 4, West Hartford, Connecticut |
| Authorized Official Name and Position | Angel C. Jaquez (DIRECTOR) |
| Authorized Official Contact | 8602181725 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| West Hartford Medical Center 74 Park Rd Ste 4 West Hartford CT 06119-1898 Ph: (860) 218-1725 | West Hartford Medical Center 74 Park Rd Ste 4 West Hartford CT 06119-1898 Ph: (860) 218-1725 |
| NPI Number | 1942533039 |
|---|---|
| Provider Enumeration Date | 09/08/2009 |
| Last Update Date | 12/18/2012 |
| Medicare PECOS PAC ID | 4284764598 |
|---|---|
| Medicare Enrollment ID | O20100614000298 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1942533039 | NPI | - | NPPES |
| 008022952 | Medicaid | CT | |
| 6464646 | Medicaid | CT |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 208100000X | Physical Medicine & Rehabilitation | (* (Not Available)) | Secondary |
| Provider Name | Corey A Jaquez |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1205073962 PECOS PAC ID: 8628105210 Enrollment ID: I20100430000472 |
| Provider Name | Igor V Samegulin |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1255517249 PECOS PAC ID: 7416136668 Enrollment ID: I20110120000612 |
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