Healthcare Provider Details

I. General information

NPI: 1710927561
Provider Name (Legal Business Name): PHILLIS BEBERMAN-JENNES DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 MAIN ST SUITE 202
BRIDGEPORT CT
06606
US

IV. Provider business mailing address

4920 MAIN ST SUITE 202
BRIDGEPORT CT
06606-1300
US

V. Phone/Fax

Practice location:
  • Phone: 203-374-1515
  • Fax: 203-374-4702
Mailing address:
  • Phone: 203-374-1515
  • Fax: 203-374-4702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number000424
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: