CLEANSLATE MEDICAL GROUP OF CONNECTICUT LLC (NPI# 1073057071) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1073057071 |
| Entity Type | Organization |
| Organization Name | CLEANSLATE MEDICAL GROUP OF CONNECTICUT LLC |
| Practice Address |
85 Gillett St Hartford CT 06105-2630 |
| Mailing Address |
15 Century Blvd Ste 307 Nashville TN 37214-3692 |
| Practice Telephone | 6154250220 |
| Practice Fax Number | 4137273619 |
| Mailing Telephone | 6154250220 |
| Mailing Fax Number | 4137273619 |
| Enumeration Date | 2016-12-09 |
| Last Update Date | 2019-07-02 |
| Authorized Official Name | ROBERT HUTCHISON (CFO) |
| Authorized Official Telephone | 6154250220 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 207R00000X | Internal Medicine | Allopathic & Osteopathic Physicians | ||
| Y | 207RA0401X |
Internal Medicine Specialization: Addiction Medicine |
Allopathic & Osteopathic Physicians |
| Street Address |
85 GILLETT ST |
| City | HARTFORD |
| State | CT |
| Zip Code | 06105-2630 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1770196180 | Asham Hamilton | Counselor | 85 Gillett St, Hartford, CT 06105-2630 | 2020-08-25 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1275155939 | Pruthwy R Addanki | Student in an Organized Health Care Education/Training Program | Saint Francis Clinic, 1000 Asylum Avenue, Suite 1004, Hartford, CT 06105 | 2020-05-15 |
| 1700447802 | Samuel Flynn | Student in an Organized Health Care Education/Training Program | 1000 Asylum Avenue, Suite 3200, Hartford, CT 06105 | 2019-06-28 |
| 1730743568 | Turab J Mohammed | Student in an Organized Health Care Education/Training Program | Saint Francis Hospital Clinic, 1000 Asylum Avenue, Suite 1004, Hartford, CT 06105 | 2019-04-26 |
| 1164900387 | Breanne Ferrara | Social Worker | 43 Wooland St, Hartford, CT 06105 | 2018-07-31 |
| 1154814069 | Signature Smiles of Hartford LLC | Dentist | 550 Farmington Avenue, Suite B, Hartford, CT 06105 | 2018-06-14 |
| 1356839062 | Jaimy Villavicencio | Student in an Organized Health Care Education/Training Program | 100 Asylum Avenue, Suite 1004, Hartford, CT 06105 | 2018-04-27 |
| 1750885679 | Brittany Bird | Student in an Organized Health Care Education/Training Program | 839-841 Asylum Avenue, Hartford, CT 06105 | 2018-03-23 |
| 1972032241 | Ashley Nicole Mills | Student in an Organized Health Care Education/Training Program | 896 Asylum Ave, 3rd Floor, Hartford, CT 06105 | 2017-06-08 |
| 1528506847 | Samuel Agyei | Social Worker | 291 Collins St, Hartford, CT 06105 | 2017-02-07 |
| 1841735818 | Katie Strahowski | Nurse Practitioner | 85 Gillett Street, Clean Slate, Hartford, CT 06105 | 2016-12-30 |
| Find all providers in zip 06105 | ||||
| Taxonomy Code | 207RA0401X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Internal Medicine |
| Specialization | Addiction Medicine |
| An internist doctor of osteopathy that specializes in the treatment of addiction disorders. A doctor of osteopathy that is board eligible/certified by the American Osteopathic Board of Internal Medicine can obtain a Certificate of Added Qualifications in the field of Addiction Medicine. |
| Notes: Source: American Osteopathic Board of Internal Medicine, 2007. [7/1/2008: added definition, added source; 7/1/2011: modified source] - Additional Resources: http://www.osteopathic.org/certification |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1922215821 | Luke E O'connor | Internal Medicine | 23 Ellington Ave, Po 878 Willimantic Ct 06022, Ellington, CT 06029 | 2007-05-17 |
| 1962797696 | Genevieve Montagu Von Walstrom | Internal Medicine | 17 Wall St, Madison, CT 06443-3122 | 2011-06-10 |
| 1801103858 | Richard N. Goldberg Md, PC | Internal Medicine | 211 New Britain Rd, Suite 206, Kensington, CT 06037 | 2010-09-10 |
| 1376618611 | Ebenezer Kolade | Internal Medicine | 3851 Main St, Bridgeport, CT 06606-2864 | 2006-11-22 |
| 1891889010 | Bridget Ann Martell | Internal Medicine | 20 York St., Yale University Section of General Internal Medicine, New Haven, CT 06520 | 2006-10-03 |
| 1952318214 | Deepa Camenga | Internal Medicine | 20 York St, New Haven, CT 06510-3220 | 2006-08-01 |
| 1659340651 | Nermina Bukalo | Internal Medicine | 71 Haynes St, Manchester, CT 06040-4131 | 2006-03-14 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.