Healthcare Provider Details

I. General information

NPI: 1174201156
Provider Name (Legal Business Name): MDLIVE MEDICAL GROUP NM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 COTTAGE GROVE RD
BLOOMFIELD CT
06002-2920
US

IV. Provider business mailing address

PO BOX 5006
HARTFORD CT
06102-5006
US

V. Phone/Fax

Practice location:
  • Phone: 800-400-6354
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUE-ANN ADRIANS
Title or Position: GP PM
Credential:
Phone: 800-400-6354