Healthcare Provider Details

I. General information

NPI: 1124117908
Provider Name (Legal Business Name): INTERANAL MEDICINE AND PEDIATRIC ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 PALOMBA DR SUITE 13
ENFIELD CT
06082-3888
US

IV. Provider business mailing address

15 PALOMBA DR SUITE 13
ENFIELD CT
06082-3888
US

V. Phone/Fax

Practice location:
  • Phone: 860-749-2251
  • Fax: 860-745-7747
Mailing address:
  • Phone: 860-749-2251
  • Fax: 860-745-7747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JOYCE FONG-BRETON
Title or Position: OWNER
Credential: MD
Phone: 860-749-2251