Provider Demographics
NPI:1285624809
Name:TALLY, KEVIN J (MD)
Entity type:Individual
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First Name:KEVIN
Middle Name:J
Last Name:TALLY
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Gender:M
Credentials:MD
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Mailing Address - Street 1:305 WESTERN BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4380
Mailing Address - Country:US
Mailing Address - Phone:860-522-0604
Mailing Address - Fax:860-522-1761
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 719
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-522-0604
Practice Address - Fax:860-522-1761
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2015-05-20
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Provider Licenses
StateLicense IDTaxonomies
CT042086207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001420869Medicaid
CTC00585OtherPTAN CONS. CARDIOLOGISTS
CT010042086CT01OtherANTHEM BCBS
CT060001631OtherMCPIN CT HEART PHYSICIANS
CTCA7937OtherRAILROAD MEDICARE GROUP #
CTP00233421OtherRAILROAD MEDICARE
CTI03582Medicare UPIN
CT060001588Medicare PIN
CT060001631OtherMCPIN CT HEART PHYSICIANS
CT001420869Medicaid