Provider Demographics
NPI:1962783381
Name:HARTFORD CLINICAL ASSOCIATES, PC
Entity type:Organization
Organization Name:HARTFORD CLINICAL ASSOCIATES, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FUNDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-545-7188
Mailing Address - Street 1:17 TALCOTT NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1818
Mailing Address - Country:US
Mailing Address - Phone:860-524-2626
Mailing Address - Fax:860-677-5029
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 409
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-547-0616
Practice Address - Fax:860-524-2655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT208800000X
213E00000X, 213ES0103X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00177Medicare PIN
CT6612990004Medicare NSC