Provider Demographics
NPI:1285880088
Name:GRACE CENTER FOR HEMATOLOGY & ONCOLOGY CARE LLC
Entity type:Organization
Organization Name:GRACE CENTER FOR HEMATOLOGY & ONCOLOGY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:TJAN-WETTSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-539-3360
Mailing Address - Street 1:45 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-8105
Mailing Address - Country:US
Mailing Address - Phone:860-539-3360
Mailing Address - Fax:
Practice Address - Street 1:45 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-8105
Practice Address - Country:US
Practice Address - Phone:860-539-3360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036026207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty