MEDICARE: STAYWELL PEDIATRIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	000373	CT

General Provider Information

NPI Number	:	1255521019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STAYWELL PEDIATRIC LLC

Provider Business Mailing Address
First Line	:	365 ELM ST
Second Line	:
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-4217
Country	:	US
Telephone Number	:	203-932-3227
Fax Number	:	203-931-2847

Provider Business Practice Location Address
First Line	:	365 ELM ST
Second Line	:
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-4217
Country	:	US
Telephone Number	:	203-932-3227
Fax Number	:	203-931-2847

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THOMAS ETKIN
Credential	:	M.D.
Telephone Number	:	230-932-3227

Provider Enumeration Date	:	07/27/2007
Last Update Date	:	07/27/2007

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