Healthcare Provider Details

I. General information

NPI: 1659569416
Provider Name (Legal Business Name): PLASTIC SURGERY OF GREATER HARTFORD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNARD LN SUITE 102
BLOOMFIELD CT
06002-2481
US

IV. Provider business mailing address

1 BARNARD LN SUITE 102
BLOOMFIELD CT
06002-2481
US

V. Phone/Fax

Practice location:
  • Phone: 860-243-1889
  • Fax: 860-243-5733
Mailing address:
  • Phone: 860-243-1889
  • Fax: 860-243-5733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number034529
License Number StateCT

VIII. Authorized Official

Name: JONATHAN S SCHREIBER
Title or Position: OWNER
Credential: MD
Phone: 860-243-1889