Provider Demographics
NPI:1194091967
Name:EXECUTIVE HEALTH GROUP OF CONNECTICUT, PC
Entity type:Organization
Organization Name:EXECUTIVE HEALTH GROUP OF CONNECTICUT, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTING
Authorized Official - Prefix:MS
Authorized Official - First Name:ROXANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-332-3725
Mailing Address - Street 1:10 ROCKEFELLER PLZ FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10020-1903
Mailing Address - Country:US
Mailing Address - Phone:212-332-3700
Mailing Address - Fax:
Practice Address - Street 1:750 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-3722
Practice Address - Country:US
Practice Address - Phone:203-348-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty