Healthcare Provider Details

I. General information

NPI: 1710935002
Provider Name (Legal Business Name): COTTAGE GROVE CARDIOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 COTTAGE GROVE ROAD
BLOOMFIELD CT
06002-3060
US

IV. Provider business mailing address

711 COTTAGE GROVE ROAD
BLOOMFIELD CT
06002-3060
US

V. Phone/Fax

Practice location:
  • Phone: 860-242-8756
  • Fax: 860-242-3052
Mailing address:
  • Phone: 860-242-8756
  • Fax: 860-242-3052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number002892
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3110
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5854
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: STACY SIMONS
Title or Position: OFFICE ASSISTANT
Credential:
Phone: 860-242-8756