Healthcare Provider Details

I. General information

NPI: 1699026724
Provider Name (Legal Business Name): ADVANCED GYNECOLOGY & ROBOTIC SURGEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4637 MAIN STREET
BRIDGEPORT CT
06606-5048
US

IV. Provider business mailing address

4637 MAIN STREET
BRIDGEPORT CT
06606-5048
US

V. Phone/Fax

Practice location:
  • Phone: 203-374-8000
  • Fax:
Mailing address:
  • Phone: 203-374-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number045088
License Number StateCT

VIII. Authorized Official

Name: DR. SHABNAM M KASHANI
Title or Position: OWNER
Credential: M.D
Phone: 203-374-8000