Healthcare Provider Details

I. General information

NPI: 1194712596
Provider Name (Legal Business Name): ASSOCIATED NEUROLOGISTS OF SOUTHERN CONNECTICUT, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 KINGS HIGHWAY CUTOFF 5TH FLOOR
FAIRFIELD CT
06824-5340
US

IV. Provider business mailing address

75 KINGS HIGHWAY CUTOFF 5TH FLOOR
FAIRFIELD CT
06824-5340
US

V. Phone/Fax

Practice location:
  • Phone: 203-333-1133
  • Fax: 203-333-3937
Mailing address:
  • Phone: 203-333-1133
  • Fax: 203-333-3937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: DR. KENNETH COLEMAN SIEGEL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 203-333-1133